Provider Demographics
NPI:1225514904
Name:LOPEZ, ROMAN
Entity Type:Individual
Prefix:
First Name:ROMAN
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 1:13105 KESTREL AVE
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-6210
Mailing Address - Country:US
Mailing Address - Phone:915-235-5200
Mailing Address - Fax:
Practice Address - Street 1:11351 JAMES WATT DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6627
Practice Address - Country:US
Practice Address - Phone:915-849-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2098176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty