Basic Information
| Provider Information | |||||||||
| NPI: | 1104400126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | CESAR | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2440 E OLYMPUS DR | ||||||||
| Address2: | |||||||||
| City: | HOLLADAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841242814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404419643 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 177 FORT WASHINGTON AVE FL 7 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038212305 | ||||||||
| FaxNumber: | 2123058321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.