Provider Demographics
NPI:1508050238
Name:LUIS ALFONSO LOPEZ, MD, PA
Entity Type:Organization
Organization Name:LUIS ALFONSO LOPEZ, MD, PA
Other - Org Name:LITTLE BUDDIES PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-650-0814
Mailing Address - Street 1:20642 STONE OAK PARKWAY
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-650-0814
Mailing Address - Fax:210-650-0926
Practice Address - Street 1:20642 STONE OAK PARKWAY
Practice Address - Street 2:STE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-650-0814
Practice Address - Fax:210-650-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1530208000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1732737-02Medicaid
TX173273703Medicaid
TX1732737-01Medicaid
TX173273704Medicaid