Provider Demographics
NPI:1174575484
Name:LOPEZ, GERARDO C (MD)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:C
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 304
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:304-933-3830
Mailing Address - Fax:304-933-3837
Practice Address - Street 1:527 MEDICAL PARK DR STE 304
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-933-3830
Practice Address - Fax:304-933-3837
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17559207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0081763000Medicaid
WV001720850OtherBLUE CROSS BLUE SHEILD
WVWV17559AOtherHEALTH PLAN
WV001720850OtherBLUE CROSS BLUE SHEILD
WVG74399Medicare UPIN
WV0081763000Medicaid