Provider Demographics
NPI:1518958040
Name:LOPEZ, ALFREDO M (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2060 N SHADELAND AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1764
Mailing Address - Country:US
Mailing Address - Phone:317-635-3499
Mailing Address - Fax:317-635-0449
Practice Address - Street 1:2060 N SHADELAND AVE
Practice Address - Street 2:STE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1764
Practice Address - Country:US
Practice Address - Phone:317-635-3499
Practice Address - Fax:317-635-0449
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01046966A208D00000X, 2084N0400X
IL036-0911922084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200240820Medicaid
IN200240820Medicaid
ING99446Medicare UPIN