Provider Demographics
NPI:1215306675
Name:LOPEZ, BRYAN (IDC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 455 BOX 182
Mailing Address - Street 2:MEDICAL DEPARTMENT
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96540-1182
Mailing Address - Country:US
Mailing Address - Phone:671-339-6287
Mailing Address - Fax:
Practice Address - Street 1:PSC 455 BOX 182
Practice Address - Street 2:MEDICAL DEPARTMENT, NAVSPECWAUNIT ONE
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96540-1182
Practice Address - Country:US
Practice Address - Phone:671-339-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider