Provider Demographics
NPI:1801974241
Name:LOPEZ, JUAN S (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:S
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SAGEMAN STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-699-0989
Mailing Address - Fax:
Practice Address - Street 1:64 NAGLE AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1406
Practice Address - Country:US
Practice Address - Phone:646-344-1715
Practice Address - Fax:917-997-9555
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA109431-1207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology