Healthcare Provider Details

I. General information

NPI: 1952309320
Provider Name (Legal Business Name): CARLOS JAVIER LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date: 03/15/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

521 W THOMAS RD 2ND FLOOR
PHOENIX AZ
85013-4240
US

IV. Provider business mailing address

521 W THOMAS RD 2ND FLOOR
PHOENIX AZ
85013-4240
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-3133
  • Fax: 602-252-2644
Mailing address:
  • Phone: 602-254-0390
  • Fax: 800-846-8757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27821
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27821
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: