Provider Demographics
NPI:1497834832
Name:LOPEZ, JEREMIAH GUADEZ
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:GUADEZ
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 1:8811 53RD AVE
Mailing Address - Street 2:1ST FL
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4517
Mailing Address - Country:US
Mailing Address - Phone:917-605-1257
Mailing Address - Fax:
Practice Address - Street 1:8371 116TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-3448
Practice Address - Country:US
Practice Address - Phone:718-441-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist