Provider Demographics
NPI:1497862478
Name:LOPEZ, PETER P (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 N CRANBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2617
Mailing Address - Country:US
Mailing Address - Phone:305-608-5977
Mailing Address - Fax:
Practice Address - Street 1:43331 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-263-5410
Practice Address - Fax:586-263-7131
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41107208600000X
MI4301056111208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177143801Medicaid
MI1316031339OtherGROUP NPI