Provider Demographics
NPI:1114284809
Name:LOPEZ, RUDY J (SO-IDC)
Entity Type:Individual
Prefix:MR
First Name:RUDY
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:SO-IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JOINT SPECIAL OPERATIONS MEDICAL CTR
Mailing Address - Street 2:USAJFKSWCS STOP A., 3004 ARDENNES ST.
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-9610
Mailing Address - Country:US
Mailing Address - Phone:910-369-7775
Mailing Address - Fax:
Practice Address - Street 1:JOINT SPECIAL OPERATIONS MEDICAL CTR
Practice Address - Street 2:USAJFKSWCS STOP A., 3004 ARDENNES ST.
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-9610
Practice Address - Country:US
Practice Address - Phone:910-369-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNEC HM84031710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman