Provider Demographics
NPI:1295858694
Name:LOPEZ, JOAQUIN (MD)
Entity Type:Individual
Prefix:
First Name:JOAQUIN
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 1:6238 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2319
Mailing Address - Country:US
Mailing Address - Phone:708-795-5020
Mailing Address - Fax:708-795-5023
Practice Address - Street 1:6238 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2319
Practice Address - Country:US
Practice Address - Phone:708-795-5020
Practice Address - Fax:708-795-5023
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics