Provider Demographics
NPI:1548360084
Name:LOPEZ-BERMEJO, MELISSA (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LOPEZ-BERMEJO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ZOSIMA
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:243 GREEN VALLEY RD STE D
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3133
Mailing Address - Country:US
Mailing Address - Phone:831-728-6327
Mailing Address - Fax:831-761-7769
Practice Address - Street 1:243 GREEN VALLEY RD STE D
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3133
Practice Address - Country:US
Practice Address - Phone:831-728-6327
Practice Address - Fax:831-761-7769
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54168207R00000X, 207RP1001X
CAA541680207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A541680Medicaid
CA00A541680Medicaid
CAG78670Medicare UPIN