Provider Demographics
NPI:1861845315
Name:LOPEZ, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17993 PETERSEN WAY
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-1143
Mailing Address - Country:US
Mailing Address - Phone:510-723-6689
Mailing Address - Fax:
Practice Address - Street 1:17993 PETERSEN WAY
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-1143
Practice Address - Country:US
Practice Address - Phone:510-723-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer