Provider Demographics
NPI:1740512359
Name:IVAN R LOPEZ MD PC
Entity type:Organization
Organization Name:IVAN R LOPEZ MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-890-9115
Mailing Address - Street 1:PO BOX 6313
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60598-0313
Mailing Address - Country:US
Mailing Address - Phone:708-890-9115
Mailing Address - Fax:630-340-3283
Practice Address - Street 1:2003 MONTGOMERY RD
Practice Address - Street 2:SUITE 106 107
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-9078
Practice Address - Country:US
Practice Address - Phone:630-340-4211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVAN R LOPEZ MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-06
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109448Medicaid
IL36109448OtherIL LICENSE