Provider Demographics
NPI:1902837891
Name:LOPEZ, ADRIEL (OD)
Entity Type:Individual
Prefix:
First Name:ADRIEL
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 1:4436 PACK SADDLE PASS
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1624
Mailing Address - Country:US
Mailing Address - Phone:512-444-7200
Mailing Address - Fax:512-444-7489
Practice Address - Street 1:4436 PACK SADDLE PASS
Practice Address - Street 2:SUITE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1624
Practice Address - Country:US
Practice Address - Phone:512-444-7200
Practice Address - Fax:512-444-7489
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3360TG152W00000X
VA1238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112432303Medicaid
TX0925280001Medicare NSC
TXT14475Medicare UPIN
TX613910Medicare PIN