Provider Demographics
NPI:1174768964
Name:TARIN-LOPEZ, MARIA GUADALUPE (OD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:GUADALUPE
Last Name:TARIN-LOPEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-5712
Mailing Address - Country:US
Mailing Address - Phone:510-334-9423
Mailing Address - Fax:
Practice Address - Street 1:461 SKYMASTER CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1909
Practice Address - Country:US
Practice Address - Phone:707-437-4095
Practice Address - Fax:707-437-4095
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13679T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABJ376XOtherMEDICARE PTAN
CABJ376YOtherMEDICARE PTAN