Healthcare Provider Details

I. General information

NPI: 1013276807
Provider Name (Legal Business Name): JORGE LOPEZ MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49430 ROAD 426 SUITE B
OAKHURST CA
93644-8618
US

IV. Provider business mailing address

PO BOX 2588
OAKHURST CA
93644-2588
US

V. Phone/Fax

Practice location:
  • Phone: 559-683-2459
  • Fax: 559-683-6885
Mailing address:
  • Phone: 559-683-2459
  • Fax: 559-683-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG63333
License Number StateCA

VIII. Authorized Official

Name: DR. JORGE LUIS LOPEZ-AGUADO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-683-2459