Provider Demographics
NPI:1073518825
Name:LOPEZ, THALIA J (MD)
Entity Type:Individual
Prefix:DR
First Name:THALIA
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
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 667
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0667
Mailing Address - Country:US
Mailing Address - Phone:316-685-1206
Mailing Address - Fax:316-688-5208
Practice Address - Street 1:527 N GROVE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4520
Practice Address - Country:US
Practice Address - Phone:316-262-2415
Practice Address - Fax:316-264-4734
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427085207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100314100DMedicaid
KS100314100DMedicaid