Provider Demographics
NPI:1629086871
Name:LOPEZ, EDWARD MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MATTHEW
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-2541
Mailing Address - Country:US
Mailing Address - Phone:814-765-6579
Mailing Address - Fax:814-765-6570
Practice Address - Street 1:116 E PINE ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-2541
Practice Address - Country:US
Practice Address - Phone:814-765-6579
Practice Address - Fax:814-765-6570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000025152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001479858 0002Medicaid
PA190509 LQ1Medicare ID - Type Unspecified
PA001479858 0002Medicaid