Provider Demographics
NPI:1831419258
Name:LOPEZ, MELVIN A (MD)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:A
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 1:901 OAK PARK BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3409
Mailing Address - Country:US
Mailing Address - Phone:805-481-2205
Mailing Address - Fax:805-481-2206
Practice Address - Street 1:901 OAK PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3409
Practice Address - Country:US
Practice Address - Phone:805-481-2205
Practice Address - Fax:805-481-2206
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB206047OtherMEDICARE ID