Basic Information
| Provider Information | |||||||||
| NPI: | 1679082242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | GUSTAVO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 411 WESTCHESTER AVE APT 1S | ||||||||
| Address2: | |||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105733725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142170981 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 256 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105531052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146130700 | ||||||||
| FaxNumber: | 9146648189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | NY | Y |
No ID Information.