Provider Demographics
NPI:1538824495
Name:LOPEZ, ENRIQUE GETULIO (LCGC)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:GETULIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 PATERSON AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-1920
Mailing Address - Country:US
Mailing Address - Phone:732-228-9376
Mailing Address - Fax:
Practice Address - Street 1:11 GETTY AVENUE
Practice Address - Street 2:FLOOR 2
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503
Practice Address - Country:US
Practice Address - Phone:973-754-2729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MJ00061000170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS