Provider Demographics
NPI:1376651117
Name:LOZANO, IVETTE C (MD)
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:C
Last Name:LOZANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10425 GARLAND RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2926
Mailing Address - Country:US
Mailing Address - Phone:214-660-1616
Mailing Address - Fax:214-660-1628
Practice Address - Street 1:10425 GARLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-2926
Practice Address - Country:US
Practice Address - Phone:214-660-1616
Practice Address - Fax:214-660-1628
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4310261QM2500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135757601Medicaid
TX135757601Medicaid
TX00R22AMedicare PIN