Provider Demographics
NPI:1528018504
Name:LOPEZ, JORGE ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ROBERTO
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 1:1168 SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4236
Mailing Address - Country:US
Mailing Address - Phone:626-288-4741
Mailing Address - Fax:626-288-4797
Practice Address - Street 1:1168 SAN GABRIEL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4236
Practice Address - Country:US
Practice Address - Phone:626-288-4741
Practice Address - Fax:626-288-4797
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG61816OtherMEDICAL LICENSE
CA00G618160OtherBLUE CROSS/BLUE SHIELD
CA00G618161Medicaid
CA00G618160OtherBLUE CROSS/BLUE SHIELD
CAG61816OtherMEDICAL LICENSE