Provider Demographics
NPI:1275963761
Name:LOPEZ, JEREMIAH
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ETHAN
Other - Middle Name:
Other - Last Name:ORR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27669
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85726-7669
Mailing Address - Country:US
Mailing Address - Phone:520-571-8600
Mailing Address - Fax:520-571-8700
Practice Address - Street 1:1651 W GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1433
Practice Address - Country:US
Practice Address - Phone:520-571-8600
Practice Address - Fax:520-571-8700
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor