Provider Demographics
NPI:1245222090
Name:LOPATNIUK-LOPEZ, JOLANTA A (MD)
Entity Type:Individual
Prefix:
First Name:JOLANTA
Middle Name:A
Last Name:LOPATNIUK-LOPEZ
Suffix:
Gender:F
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:4500 W 181ST AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-0017
Practice Address - Country:US
Practice Address - Phone:219-690-2016
Practice Address - Fax:219-690-1862
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058508A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0090000854OtherBCBS GROUP NUMBER
IN200465220Medicaid
IN200465220Medicaid
IN140220OOOMedicare PIN