Provider Demographics
NPI:1578136255
Name:MEDINA LOPEZ, MONICA M
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:M
Last Name:MEDINA LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 STAPLEHURST ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-3656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5122 STAPLEHURST ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-3656
Practice Address - Country:US
Practice Address - Phone:361-489-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical TechniciansGroup - Multi-Specialty