Basic Information
| Provider Information | |||||||||
| NPI: | 1285815787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 JUNIPER DR | ||||||||
| Address2: | |||||||||
| City: | EAST GREENWICH | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028181353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177638644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 SOCKANOSSET CROSS RD | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029205536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018864830 | ||||||||
| FaxNumber: | 8887797670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 01/25/2014 | ||||||||
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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 | 2085R0202X | MD14295 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | ML93346 | 05 | RI | MEDICAID |