Provider Demographics
NPI:1376643007
Name:LOPEZ, LEONARDO (MD)
Entity Type:Individual
Prefix:
First Name:LEONARDO
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 1:1311 MEMORIAL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-3013
Mailing Address - Country:US
Mailing Address - Phone:815-539-3141
Mailing Address - Fax:815-538-1838
Practice Address - Street 1:1311 MEMORIAL DR STE 500
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-3013
Practice Address - Country:US
Practice Address - Phone:815-539-3141
Practice Address - Fax:815-487-4901
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098968OtherLICENSE
IL336059388OtherCONTROLLED SUB. LICENSE
ILBL6101935OtherDEA
IL336059388OtherCONTROLLED SUB. LICENSE
ILG91020Medicare UPIN
IL5872260001Medicare NSC