Provider Demographics
NPI:1558396408
Name:LOPEZ, ROLANDO R (PA)
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6027
Mailing Address - Country:US
Mailing Address - Phone:203-744-9700
Mailing Address - Fax:203-744-9701
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-739-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT975207X00000X
CT000975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP12474Medicare UPIN
CT9700000624Medicare ID - Type Unspecified