Provider Demographics
NPI:1841419785
Name:OCTAVIO M. LOPEZ MD SC
Entity Type:Organization
Organization Name:OCTAVIO M. LOPEZ MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-448-8899
Mailing Address - Street 1:11315 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-2025
Mailing Address - Country:US
Mailing Address - Phone:708-448-8899
Mailing Address - Fax:708-448-9988
Practice Address - Street 1:11315 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-2025
Practice Address - Country:US
Practice Address - Phone:708-448-8899
Practice Address - Fax:708-448-9988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E43657Medicare UPIN
IL921601Medicare ID - Type Unspecified