Provider Demographics
NPI:1861543332
Name:LOPEZ, JESUS ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:ANTONIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:601 LABOR ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78210-1313
Mailing Address - Country:US
Mailing Address - Phone:210-921-6088
Mailing Address - Fax:210-921-6019
Practice Address - Street 1:601 LABOR ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-1313
Practice Address - Country:US
Practice Address - Phone:210-921-6088
Practice Address - Fax:210-921-6019
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14408361Medicaid
TXG53860Medicare UPIN
TX14408361Medicaid