Provider Demographics
NPI:1851057798
Name:LOPEZ, ALEX (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21712 KELLY ANN LN
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-7684
Mailing Address - Country:US
Mailing Address - Phone:779-225-5603
Mailing Address - Fax:
Practice Address - Street 1:20006 WOLF RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1320
Practice Address - Country:US
Practice Address - Phone:708-478-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist