Healthcare Provider Details

I. General information

NPI: 1033747860
Provider Name (Legal Business Name): EDGAR RUBEN LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 12/22/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 STOCKDALE HWY
BAKERSFIELD CA
93309-2150
US

IV. Provider business mailing address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 773-296-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA188069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: