Provider Demographics
NPI:1104391200
Name:LOPEZ, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 DEL REY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5752
Mailing Address - Country:US
Mailing Address - Phone:619-995-0303
Mailing Address - Fax:
Practice Address - Street 1:5562 PHILADELPHIA ST STE 301
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2499
Practice Address - Country:US
Practice Address - Phone:214-868-4371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95155507163W00000X
CA95023964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty