Provider Demographics
NPI:1073599619
Name:LOPEZ, ABRAHAM DAGOBERTO JR (PA)
Entity Type:Individual
Prefix:MR
First Name:ABRAHAM
Middle Name:DAGOBERTO
Last Name:LOPEZ
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4518 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-3027
Mailing Address - Country:US
Mailing Address - Phone:602-320-0580
Mailing Address - Fax:602-354-4171
Practice Address - Street 1:5102 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1703
Practice Address - Country:US
Practice Address - Phone:623-848-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2816207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ817827Medicaid
AZ860373636OtherHUMANA-GROUP #
AZ453051001OtherGROUP HEALTH GROUP
AZ3987220OtherEYECARE
AZAW1436OtherHEALTHNET GROUP