Provider Demographics
NPI:1588121701
Name:LOPEZ, MARCO ANTONIO (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1295
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90294-1295
Mailing Address - Country:US
Mailing Address - Phone:888-859-0145
Mailing Address - Fax:
Practice Address - Street 1:6080 CENTER DR FL 6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-9205
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030303225100000X
NMPT6025225100000X
TX1356673225100000X
HIPT-5253225100000X
ID7537225100000X
NY047305225100000X
AK179167225100000X
FLPT37413225100000X
MTPTP-PT-LIC-21777225100000X
IN05014421A225100000X
WYPT-2085225100000X
NV4705225100000X
CAPT294380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist