Provider Demographics
NPI:1750009635
Name:LOPEZ, NOE ENRIQUE (IDC STUDENT)
Entity type:Individual
Prefix:
First Name:NOE
Middle Name:ENRIQUE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:IDC STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9510 AUTUMN RUN LN
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-4650
Mailing Address - Country:US
Mailing Address - Phone:832-317-8493
Mailing Address - Fax:
Practice Address - Street 1:33 ABHC
Practice Address - Street 2:BLDG 330305
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman