Provider Demographics
NPI:1649871849
Name:LOPEZ, DORIAN GERALDO
Entity type:Individual
Prefix:
First Name:DORIAN
Middle Name:GERALDO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12644 COUNCIL OAK DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3585
Mailing Address - Country:US
Mailing Address - Phone:301-442-7370
Mailing Address - Fax:
Practice Address - Street 1:12644 COUNCIL OAK DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3585
Practice Address - Country:US
Practice Address - Phone:301-442-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide