Provider Demographics
NPI:1922349968
Name:LOPEZ, JOSE ISRAEL (IDC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ISRAEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MDSU-1 BISHOP POINT
Mailing Address - Street 2:BUILDING 17
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HI
Mailing Address - Zip Code:96860
Mailing Address - Country:US
Mailing Address - Phone:808-471-9292
Mailing Address - Fax:
Practice Address - Street 1:MDSU-1 BISHOP POINT
Practice Address - Street 2:BUILDING 17
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:808-471-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman