Provider Demographics
NPI:1790184141
Name:HORACIO G LOPEZ, M.D. , INC
Entity Type:Organization
Organization Name:HORACIO G LOPEZ, M.D. , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HORACIO
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-353-3600
Mailing Address - Street 1:2105 BEVERLY BLVD STE 129
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2262
Mailing Address - Country:US
Mailing Address - Phone:213-353-3600
Mailing Address - Fax:
Practice Address - Street 1:2105 BEVERLY BLVD STE 129
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2262
Practice Address - Country:US
Practice Address - Phone:213-353-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48199261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE54043Medicare UPIN