Provider Demographics
NPI:1396476966
Name:LOPEZ, DAVID ANTHONY
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
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 1:2345 HAPPY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-8076
Mailing Address - Country:US
Mailing Address - Phone:270-678-5250
Mailing Address - Fax:270-678-2647
Practice Address - Street 1:2345 HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-8076
Practice Address - Country:US
Practice Address - Phone:270-678-5250
Practice Address - Fax:270-678-2647
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY277032156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician