Provider Demographics
NPI:1295880425
Name:LOPEZ, KRISTOPHER M (DPM)
Entity type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4715
Mailing Address - Country:US
Mailing Address - Phone:773-248-4111
Mailing Address - Fax:773-248-4450
Practice Address - Street 1:3632 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4715
Practice Address - Country:US
Practice Address - Phone:773-248-4111
Practice Address - Fax:773-248-4450
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005291213ES0103X
IL016005291213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636066OtherBLUE CROSS BLUE SHIELD
IL016005291Medicaid
ILR02563Medicare PIN