Provider Demographics
NPI:1841400306
Name:RONALD F LOPEZ MD LLC
Entity Type:Organization
Organization Name:RONALD F LOPEZ MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-572-3750
Mailing Address - Street 1:PO BOX 150610
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0610
Mailing Address - Country:US
Mailing Address - Phone:801-476-9200
Mailing Address - Fax:801-476-9208
Practice Address - Street 1:12176 S 1000 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9716
Practice Address - Country:US
Practice Address - Phone:801-572-3750
Practice Address - Fax:801-572-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188509-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT55661149801001OtherBLUE CROSS BLUE SHIELD
UTF83978Medicare UPIN