Provider Demographics
NPI:1487648051
Name:LOPEZ, MARK T (ODPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ODPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 LONG COVE RD
Mailing Address - Street 2:
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:860-464-7013
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004021507Medicaid
CT090000856CT01OtherBC/BS
CT1487648051OtherVSP VISION SERVICE PLAN
CT0V2229OtherHEALTHNET
CT004021507Medicaid
CTD400011046Medicare PIN
CT090000856CT01OtherBC/BS
CT1487648051OtherVSP VISION SERVICE PLAN