Provider Demographics
NPI:1922009190
Name:LOPEZ, JOSE R (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-783-6842
Practice Address - Street 1:910 WORTH STREET
Practice Address - Street 2:FOOTHILLS PRIMARY CARE
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-783-6842
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2012-00004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919100Medicaid
NC5919100Medicaid
NCNC3328AMedicare PIN