Healthcare Provider Details

I. General information

NPI: 1194816140
Provider Name (Legal Business Name): EDWARD JOSEPH LOPEZ D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 17TH ST
COLUMBUS GA
31901-3500
US

IV. Provider business mailing address

PO BOX 9247
COLUMBUS GA
31908-9247
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-7884
  • Fax: 706-243-4355
Mailing address:
  • Phone: 706-322-7884
  • Fax: 706-243-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number246
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1541
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE-3603
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000814
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: