1285699199 NPI number — JOSEPHINE T LOPEZ MD

Table of content: JOSEPHINE T LOPEZ MD (NPI 1285699199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285699199 NPI number — JOSEPHINE T LOPEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JOSEPHINE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TICSAY-LOPEZ
Provider Other First Name:
JOSEPHINE
Provider Other Middle Name:
V
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1285699199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 OGLETHORPE AVE
Provider Second Line Business Mailing Address:
BLDG 100
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-543-9899
Provider Business Mailing Address Fax Number:
706-613-3995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 OGLETHORPE AVE
Provider Second Line Business Practice Location Address:
BLDG 100
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-2179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-543-9899
Provider Business Practice Location Address Fax Number:
706-613-3995
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  044125 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000754839B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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