Provider Demographics
NPI:1376715680
Name:MARK T LOPEZ OD PC
Entity Type:Organization
Organization Name:MARK T LOPEZ OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-464-6060
Mailing Address - Street 1:1026 LONG COVE RD
Mailing Address - Street 2:P.O. BOX 336
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1812
Mailing Address - Country:US
Mailing Address - Phone:860-464-6060
Mailing Address - Fax:
Practice Address - Street 1:1026 LONG COVE RD
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1812
Practice Address - Country:US
Practice Address - Phone:860-464-6060
Practice Address - Fax:860-464-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004021507Medicaid
CTD100011045Medicare PIN
CT410000291Medicare PIN
CTT22402Medicare UPIN
CT004021507Medicaid