Provider Demographics
NPI:1942904644
Name:LOPEZ, EMMANUEL OCTAVIO
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:OCTAVIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HERITAGE DR APT B
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5304
Mailing Address - Country:US
Mailing Address - Phone:917-324-0079
Mailing Address - Fax:
Practice Address - Street 1:31 HERITAGE DR APT B
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5304
Practice Address - Country:US
Practice Address - Phone:917-324-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator