Provider Demographics
NPI:1669517652
Name:LOPEZ, MARTIN
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
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 1:2302 S MARTIN L KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-4135
Mailing Address - Country:US
Mailing Address - Phone:559-442-0400
Mailing Address - Fax:559-442-0401
Practice Address - Street 1:2302 S MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-4135
Practice Address - Country:US
Practice Address - Phone:559-442-0400
Practice Address - Fax:559-442-0401
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC8291214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)