Provider Demographics
NPI:1679791065
Name:LOPEZ, IRMA LILIANA (OD)
Entity Type:Individual
Prefix:DR
First Name:IRMA
Middle Name:LILIANA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 LIBERTY AVE
Mailing Address - Street 2:UNIT 1A2
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1812
Mailing Address - Country:US
Mailing Address - Phone:718-641-3450
Mailing Address - Fax:
Practice Address - Street 1:11104 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1812
Practice Address - Country:US
Practice Address - Phone:718-641-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006453-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02602862Medicaid