Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 4301099387 | MI |
NPI | 1306134085 |
---|---|
Provider Name | Jeremiah Lopez |
First Address | East Lansing, MI 48824-7015 |
Second Address | East Lansing, MI 48824-7015 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2011 |
Last Update Date | 07/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1306134085 | (05) | MI |