Provider Demographics
NPI:1922192731
Name:LOPEZ, PERRY (OD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:
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 1:4040 E 82ND ST
Mailing Address - Street 2:C-7
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4360
Mailing Address - Country:US
Mailing Address - Phone:317-595-8855
Mailing Address - Fax:317-595-8866
Practice Address - Street 1:4040 E 82ND ST
Practice Address - Street 2:C-7
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4360
Practice Address - Country:US
Practice Address - Phone:317-595-8855
Practice Address - Fax:317-595-8866
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002200B152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT83378Medicare UPIN
IN267950CMedicare ID - Type Unspecified