Provider Demographics
NPI:1841765823
Name:LOPEZ, MARC ELIAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ELIAS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PENNY LN STE 4
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6010
Mailing Address - Country:US
Mailing Address - Phone:831-724-8235
Mailing Address - Fax:
Practice Address - Street 1:15 PENNY LN STE 4
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6010
Practice Address - Country:US
Practice Address - Phone:831-724-8235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295618225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist