Provider Demographics
NPI:1205887791
Name:VIVINO, MARIA LOUELLA LOPEZ (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA LOUELLA
Middle Name:LOPEZ
Last Name:VIVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 278984
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-784-9277
Mailing Address - Fax:585-424-7289
Practice Address - Street 1:101 SULLYS TRL
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-4552
Practice Address - Country:US
Practice Address - Phone:585-544-7979
Practice Address - Fax:585-544-7901
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME767512084N0400X
PAMD4280272084N0400X
NY2869772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003666500Medicaid
FL003666500Medicaid
PA099310Medicare ID - Type Unspecified