Provider Demographics
NPI:1417031063
Name:LOPEZ, ROBERTO DANIEL
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:DANIEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3019
Mailing Address - Country:US
Mailing Address - Phone:760-352-3336
Mailing Address - Fax:760-352-3271
Practice Address - Street 1:496 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3019
Practice Address - Country:US
Practice Address - Phone:760-352-3336
Practice Address - Fax:760-352-3271
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598937047Medicare NSC
CA5687200001Medicare NSC