Provider Demographics
NPI:1649276601
Name:LOPEZ, PEDRO JUAN (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:JUAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PEDRO
Other - Middle Name:JUAN
Other - Last Name:LOPEZ-NAVEDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:920 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-5820
Mailing Address - Country:US
Mailing Address - Phone:580-774-2835
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 3060
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9303
Practice Address - Country:US
Practice Address - Phone:580-331-3340
Practice Address - Fax:580-331-3349
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11556207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41628Medicare ID - Type Unspecified