Provider Demographics
NPI:1881705556
Name:LOPEZ, JORGE RUIZ (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:RUIZ
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRAMBLEWOOD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1280
Mailing Address - Country:US
Mailing Address - Phone:714-832-5980
Mailing Address - Fax:
Practice Address - Street 1:2740 S BRISTOL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6209
Practice Address - Country:US
Practice Address - Phone:714-825-1844
Practice Address - Fax:714-825-1848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G719471Medicaid
CAF60905Medicare UPIN