Provider Demographics
NPI:1942240700
Name:LOPEZ, AISA G (MD)
Entity Type:Individual
Prefix:DR
First Name:AISA
Middle Name:G
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8046 CRITTENDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-2909
Mailing Address - Country:US
Mailing Address - Phone:215-248-0209
Mailing Address - Fax:215-247-1286
Practice Address - Street 1:5800 RIDGE AVE
Practice Address - Street 2:ROXBOROUGH MEMORIAL HOSPITAL REHABILITATION DEPARTMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1737
Practice Address - Country:US
Practice Address - Phone:215-487-4718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-038064L225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC30446Medicare UPIN
111377Medicare ID - Type Unspecified