Provider Demographics
NPI:1336394931
Name:LOPEZ, JAIME (PT)
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 GREAT LAKES AVE
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2078
Mailing Address - Country:US
Mailing Address - Phone:281-494-4896
Mailing Address - Fax:
Practice Address - Street 1:3490 NORTH RIDGE RD.
Practice Address - Street 2:SUITE 290
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist