Provider Demographics
NPI:1063668408
Name:LOPEZ, OSCAR J (EM 4013)
Entity Type:Individual
Prefix:MR
First Name:OSCAR
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:EM 4013
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 2637
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-2637
Mailing Address - Country:US
Mailing Address - Phone:907-745-4882
Mailing Address - Fax:907-745-4882
Practice Address - Street 1:10135 STRAND DR
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-2637
Practice Address - Country:US
Practice Address - Phone:907-745-4882
Practice Address - Fax:907-745-4882
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK184136171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKEM4013Medicaid