Provider Demographics
NPI:1992845069
Name:LOPEZ, IVAN R (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:R
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 1:2003 MONTGOMERY RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-9078
Mailing Address - Country:US
Mailing Address - Phone:630-340-4211
Mailing Address - Fax:630-340-3283
Practice Address - Street 1:2003 MONTGOMERY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-9078
Practice Address - Country:US
Practice Address - Phone:630-340-4211
Practice Address - Fax:630-340-3283
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02205538OtherBCBS PROVIDER NUMBER
IL363950044OtherTAXID
IL036109448Medicaid
IL02205538OtherBCBS PROVIDER NUMBER
IL036109448Medicaid
ILK14000Medicare ID - Type Unspecified