Provider Demographics
NPI:1497199913
Name:SALVADOR LOPEZ JR PHD PC
Entity Type:Organization
Organization Name:SALVADOR LOPEZ JR PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:210-413-9779
Mailing Address - Street 1:7201 BROADWAY ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3773
Mailing Address - Country:US
Mailing Address - Phone:210-413-9779
Mailing Address - Fax:210-239-6868
Practice Address - Street 1:7201 BROADWAY ST
Practice Address - Street 2:SUITE 218
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3773
Practice Address - Country:US
Practice Address - Phone:210-413-9779
Practice Address - Fax:210-239-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX415508Medicare PIN