Provider Demographics
NPI:1568667228
Name:LOPEZ, JOSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
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 1:2648 MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-4664
Mailing Address - Country:US
Mailing Address - Phone:619-498-3755
Mailing Address - Fax:
Practice Address - Street 1:1660 BROADWAY
Practice Address - Street 2:SUITE 10
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-4856
Practice Address - Country:US
Practice Address - Phone:619-498-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE08357Medicare UPIN
CAA43301Medicare ID - Type Unspecified