Provider Demographics
NPI:1356326474
Name:LOPEZ, JUAN MIRANDA (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MIRANDA
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:PO BOX 846173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6173
Mailing Address - Country:US
Mailing Address - Phone:410-247-7500
Mailing Address - Fax:410-247-4227
Practice Address - Street 1:700 GEIPE RD STE 230
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228
Practice Address - Country:US
Practice Address - Phone:410-247-7500
Practice Address - Fax:410-247-4227
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD62197207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406269800Medicaid
MD406269800Medicaid
H48300Medicare UPIN