Provider Demographics
NPI:1649294182
Name:LOPEZ, JOSE R (MD,FAAP)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD,FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 STILLWELLS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2969
Mailing Address - Country:US
Mailing Address - Phone:732-780-3333
Mailing Address - Fax:732-780-6968
Practice Address - Street 1:470 STILLWELLS CORNER RD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2969
Practice Address - Country:US
Practice Address - Phone:732-780-3333
Practice Address - Fax:732-780-6968
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02343600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4685601Medicaid