Provider Demographics
NPI:1417976051
Name:LOPEZ, VICTOR MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
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 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:17909 SOLEDAD CANYON RD
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-3210
Practice Address - Country:US
Practice Address - Phone:661-250-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G784530Medicaid
CAG17936Medicare UPIN
CA00G784530Medicaid