Provider Demographics
NPI:1669908018
Name:LOPEZ, JOSE CARLOS (ATP)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12406 SH 155 SOUTH
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-592-6760
Mailing Address - Fax:
Practice Address - Street 1:12406 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6446
Practice Address - Country:US
Practice Address - Phone:903-592-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP88042247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other