Provider Demographics
NPI:1184714040
Name:LOPEZ, GLENN ANDREW (MD, MPH)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ANDREW
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 1/2 N HELIOTROPE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2521
Mailing Address - Country:US
Mailing Address - Phone:818-314-1738
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:818-957-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine