Provider Demographics
NPI:1649703513
Name:LOPEZ, ETHAN (DO)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 BENSDALE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78064-2037
Mailing Address - Country:US
Mailing Address - Phone:830-569-6615
Mailing Address - Fax:830-569-6714
Practice Address - Street 1:1030 BENSDALE RD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:TX
Practice Address - Zip Code:78064-2037
Practice Address - Country:US
Practice Address - Phone:830-569-6615
Practice Address - Fax:830-569-6714
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9644207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine