Provider Demographics
NPI:1679193700
Name:LOPEZ, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GALLANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 89
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:12022-0089
Mailing Address - Country:US
Mailing Address - Phone:845-416-3094
Mailing Address - Fax:
Practice Address - Street 1:46 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NY
Practice Address - Zip Code:12022-7730
Practice Address - Country:US
Practice Address - Phone:845-416-3094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine