Provider Demographics
NPI:1154305241
Name:LOPEZ, JOSE BATERINA (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:BATERINA
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 S CENTER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1957
Mailing Address - Country:US
Mailing Address - Phone:810-715-0349
Mailing Address - Fax:810-768-3446
Practice Address - Street 1:4085 S CENTER RD STE 2
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1957
Practice Address - Country:US
Practice Address - Phone:810-715-0349
Practice Address - Fax:810-768-3446
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJL047858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2621432Medicaid
MI2621432Medicaid
0250169Medicare ID - Type Unspecified