1770892200 NPI number — MRS. SOFIA MARIE LOPEZ CRISOSTOMO PT

Table of content: MRS. SOFIA MARIE LOPEZ CRISOSTOMO PT (NPI 1770892200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770892200 NPI number — MRS. SOFIA MARIE LOPEZ CRISOSTOMO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ CRISOSTOMO
Provider First Name:
SOFIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOPEZ
Provider Other First Name:
SOFIA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770892200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4016 RAINTREE RD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23321-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-488-2864
Provider Business Mailing Address Fax Number:
757-488-4735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4016 RAINTREE RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23321-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-488-2864
Provider Business Practice Location Address Fax Number:
757-488-4735
Provider Enumeration Date:
10/01/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  2305204168 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004979061 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".