Provider Demographics
NPI:1598298226
Name:LOPEZ, ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
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 1:1306 VERSAILLES RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1795
Mailing Address - Country:US
Mailing Address - Phone:859-259-2635
Mailing Address - Fax:859-254-7874
Practice Address - Street 1:1306 VERSAILLES RD STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1795
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP290207R00000X, 208000000X
KY55764207R00000X
KYR4554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty