Provider Demographics
NPI:1922764802
Name:LOPEZ, TESORO LIZETTE
Entity Type:Individual
Prefix:
First Name:TESORO
Middle Name:LIZETTE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TESORO
Other - Middle Name:LIZETTE
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15400 CHOLAME RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2480
Mailing Address - Country:US
Mailing Address - Phone:760-243-5417
Mailing Address - Fax:
Practice Address - Street 1:15400 CHOLAME RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2480
Practice Address - Country:US
Practice Address - Phone:760-243-5417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist