Provider Demographics
NPI:1326011503
Name:LOPEZ, J. ANTONIO G (MD)
Entity Type:Individual
Prefix:
First Name:J. ANTONIO
Middle Name:G
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W CURTISIAN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0107
Practice Address - Country:US
Practice Address - Phone:208-367-4278
Practice Address - Fax:208-367-5200
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56032207RC0000X
IDM-9898207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G560320Medicaid
CAP00208355OtherRAILROAD MEDICARE
CAD90037Medicare UPIN
CAP00208355OtherRAILROAD MEDICARE