Provider Demographics
NPI:1154319804
Name:LOPEZ, JAVIER (MD)
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:
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 1:5158 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44127-1533
Mailing Address - Country:US
Mailing Address - Phone:216-271-0711
Mailing Address - Fax:216-271-5473
Practice Address - Street 1:5158 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1533
Practice Address - Country:US
Practice Address - Phone:216-271-0711
Practice Address - Fax:216-271-5473
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2653301208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080433Medicaid
OH0080433Medicaid
0131764Medicare ID - Type Unspecified