Provider Demographics
NPI:1619016011
Name:LOPEZ, CLARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:R
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 1:408 HUNT LN
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2637
Mailing Address - Country:US
Mailing Address - Phone:516-627-3354
Mailing Address - Fax:
Practice Address - Street 1:60 PLAZA ST E
Practice Address - Street 2:1-O
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5040
Practice Address - Country:US
Practice Address - Phone:718-783-3919
Practice Address - Fax:718-398-0975
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine