Provider Demographics
NPI:1740449529
Name:MONTANEZ LOPEZ, CARLOS WALDO (OD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:WALDO
Last Name:MONTANEZ LOPEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 701
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158
Mailing Address - Country:US
Mailing Address - Phone:734-355-4673
Mailing Address - Fax:
Practice Address - Street 1:WALMART VISION CENTER
Practice Address - Street 2:9190 HIGHLAND RD.
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386
Practice Address - Country:US
Practice Address - Phone:248-698-9782
Practice Address - Fax:248-698-9785
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR188152W00000X
MI4901004946152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist