Provider Demographics
NPI:1083789952
Name:LOPEZ, PETER JOSEPH (PAC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOSEPH
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 WESTCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-3631
Mailing Address - Country:US
Mailing Address - Phone:708-865-8106
Mailing Address - Fax:
Practice Address - Street 1:1431 N CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1702
Practice Address - Country:US
Practice Address - Phone:773-278-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant