Provider Demographics
NPI:1740662840
Name:LOPEZ, ROBERTO (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERTO
Other - Middle Name:MAURO
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1400 W GRIFFIN PARK
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-0001
Mailing Address - Country:US
Mailing Address - Phone:956-563-7046
Mailing Address - Fax:
Practice Address - Street 1:1400 W GRIFFIN PARK
Practice Address - Street 2:SUITE 1
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-0001
Practice Address - Country:US
Practice Address - Phone:956-598-5423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31699-R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine