Provider Demographics
NPI:1467083097
Name:SISTO-LOPEZ, SAMUEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:SISTO-LOPEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4607
Mailing Address - Country:US
Mailing Address - Phone:617-720-1992
Mailing Address - Fax:
Practice Address - Street 1:102 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4607
Practice Address - Country:US
Practice Address - Phone:617-720-1992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor