Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 38MC00673900 | NJ |
N | 111NN0400X | Neurology | X0116921 | NY |
NPI | 1073838991 |
---|---|
Provider Name | Marco Antonio Lopez |
First Address | West Orange, NJ 07052-7036 |
Second Address | Clifton, NJ 07011-2252 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2010 |
Last Update Date | 04/05/2020 |