Provider Demographics
NPI:1194846717
Name:LOPEZ, ELEAZAR
Entity Type:Individual
Prefix:MR
First Name:ELEAZAR
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:PO BOX 827
Mailing Address - Street 2:103-A KAIN STREET
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-0827
Mailing Address - Country:US
Mailing Address - Phone:956-488-9616
Mailing Address - Fax:956-488-0572
Practice Address - Street 1:103A S KAIN ST
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-4221
Practice Address - Country:US
Practice Address - Phone:956-488-9616
Practice Address - Fax:956-488-0572
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0086743332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180887502Medicaid
TX180887501Medicaid
TX180887501Medicaid