Provider Demographics
NPI:1083600035
Name:LOPEZ, LUIS ALFONSO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALFONSO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:A
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20642 STONE OAK PARKWAY
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-650-0814
Mailing Address - Fax:210-650-0926
Practice Address - Street 1:20642 STONE OAK PARKWAY
Practice Address - Street 2:STE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-650-0814
Practice Address - Fax:210-650-0926
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1530208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044322802Medicaid
TX044322803Medicaid