Healthcare Provider Details

I. General information

NPI: 1932476892
Provider Name (Legal Business Name): GILBERTO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 FITZHUGH ST
BATESVILLE AR
72501-7409
US

IV. Provider business mailing address

2040 FITZHUGH ST
BATESVILLE AR
72501-7409
US

V. Phone/Fax

Practice location:
  • Phone: 870-793-3334
  • Fax:
Mailing address:
  • Phone: 870-793-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRE2695
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: