Basic Information
| Provider Information | |||||||||
| NPI: | 1205887791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIVINO | ||||||||
| FirstName: | MARIA LOUELLA | ||||||||
| MiddleName: | LOPEZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 278984 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857849277 | ||||||||
| FaxNumber: | 5854247289 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SULLYS TRL | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145344552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855447979 | ||||||||
| FaxNumber: | 5855447901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME76751 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD428027 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 286977 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 003666500 | 05 | FL | MEDICAID |