Provider Demographics
NPI:1649273293
Name:LOPEZ, D. A (MD)
Entity type:Individual
Prefix:DR
First Name:D.
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:D.
Other - Middle Name:A
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:230 PROSPECT PL
Mailing Address - Street 2:STE 260
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1987
Mailing Address - Country:US
Mailing Address - Phone:619-437-1146
Mailing Address - Fax:619-437-1912
Practice Address - Street 1:230 PROSPECT PL
Practice Address - Street 2:STE 260
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1987
Practice Address - Country:US
Practice Address - Phone:619-437-1146
Practice Address - Fax:619-437-1912
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10411207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G104110Medicaid
CA00G104110Medicaid
D84482Medicare UPIN