Provider Demographics
NPI:1396701694
Name:LOPEZ GONZALEZ, JOSE A (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:LOPEZ GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5555 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4709
Mailing Address - Country:US
Mailing Address - Phone:480-393-0575
Mailing Address - Fax:480-704-4019
Practice Address - Street 1:1810 S CRISMON RD
Practice Address - Street 2:SUITE 191
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3717
Practice Address - Country:US
Practice Address - Phone:480-393-0575
Practice Address - Fax:480-704-4019
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17667208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ867856Medicaid
AZ867856Medicaid
AZ83266Medicare ID - Type UnspecifiedMEDICARE NUMBER