Provider Demographics
NPI:1578572087
Name:LOPEZ, ENRIQUE SION (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:SION
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:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85311-0066
Mailing Address - Country:US
Mailing Address - Phone:623-847-5300
Mailing Address - Fax:623-847-5304
Practice Address - Street 1:5002 W GLENDALE AVE STE 104
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301
Practice Address - Country:US
Practice Address - Phone:623-847-5300
Practice Address - Fax:623-847-5304
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101237208000000X
AZ35764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912936Medicaid
NCH64986Medicare UPIN