Provider Demographics
NPI:1679247787
Name:LOPEZ, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name: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 1:822 VIA DEL SUR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4312
Mailing Address - Country:US
Mailing Address - Phone:972-974-8216
Mailing Address - Fax:
Practice Address - Street 1:401 W CENTERVILLE RD STE 1
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5400
Practice Address - Country:US
Practice Address - Phone:972-840-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856810207Q00000X
TX1049199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty