Provider Demographics
NPI:1316509284
Name:LOPEZ, CHRISTIAN JOSUE (175T00000X)
Entity type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:JOSUE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:175T00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1539
Mailing Address - Country:US
Mailing Address - Phone:716-566-7771
Mailing Address - Fax:
Practice Address - Street 1:262 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1539
Practice Address - Country:US
Practice Address - Phone:716-566-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist