Individual
MICHAEL LOPEZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
403 LAKE DR, MEDFORD, NY 11763-4606
(718) 578-1375
Mailing address
403 LAKE DR, MEDFORD, NY 11763-4606
(718) 578-1375
Taxonomy
Speciality
Code
Description
License number
State
133N00000X
Nutritionist
Primary
—
NY
133V00000X
Registered Dietitian
—
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000567890
—
NY
Enumeration date
09/22/2018
Last updated
09/22/2018
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