Provider Demographics
NPI:1407344302
Name:LOPEZ, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40918 N PARKER CT
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-2712
Mailing Address - Country:US
Mailing Address - Phone:480-735-8934
Mailing Address - Fax:
Practice Address - Street 1:16811 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3404
Practice Address - Country:US
Practice Address - Phone:360-735-8100
Practice Address - Fax:360-253-1781
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61159118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program