Provider Demographics
NPI:1659515823
Name:LOPEZ, BASILIO ESPINO (PT)
Entity Type:Individual
Prefix:MR
First Name:BASILIO
Middle Name:ESPINO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 RYDER PL STE 1000
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-1200
Mailing Address - Country:US
Mailing Address - Phone:516-665-2023
Mailing Address - Fax:888-773-1644
Practice Address - Street 1:21 RYDER PL STE 1000
Practice Address - Street 2:
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1200
Practice Address - Country:US
Practice Address - Phone:516-665-2023
Practice Address - Fax:888-773-1644
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027734-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03487501Medicaid
NYJ400059619Medicare Oscar/Certification
NYA400058958Medicare Oscar/Certification
NYG400059363Medicare Oscar/Certification