Provider Demographics
NPI:1336352772
Name:LOPES, TERCIO (MD)
Entity Type:Individual
Prefix:
First Name:TERCIO
Middle Name:
Last Name:LOPES
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 1:1378 NW 124TH ST
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8151
Mailing Address - Country:US
Mailing Address - Phone:515-288-6097
Mailing Address - Fax:
Practice Address - Street 1:1378 NW 124TH ST
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8151
Practice Address - Country:US
Practice Address - Phone:515-288-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27245207RG0100X
MN104509207RG0100X
390200000X
MN52288207RG0100X
IA38798207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MN100000812Medicare PIN