Provider Demographics
NPI:1992972079
Name:CECILIA G. LOPEZ, MD,PC
Entity type:Organization
Organization Name:CECILIA G. LOPEZ, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-744-3321
Mailing Address - Street 1:3020 S GENESEE RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1420
Mailing Address - Country:US
Mailing Address - Phone:810-744-3321
Mailing Address - Fax:810-744-2850
Practice Address - Street 1:3020 S GENESEE RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1420
Practice Address - Country:US
Practice Address - Phone:810-744-3321
Practice Address - Fax:810-744-2850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CECILIA G. LOPEZ, MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICL046551208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3719565Medicaid