Provider Demographics
NPI:1922117571
Name:LOPEZ, LOUIS ALFRED (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ALFRED
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2106
Mailing Address - Country:US
Mailing Address - Phone:260-423-1331
Mailing Address - Fax:260-422-1046
Practice Address - Street 1:604 W BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2106
Practice Address - Country:US
Practice Address - Phone:260-423-1331
Practice Address - Fax:260-422-1046
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045695A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200108750AMedicaid
IN141360BMedicare ID - Type Unspecified