Healthcare Provider Details

I. General information

NPI: 1952183774
Provider Name (Legal Business Name): ANTONIO TOMBO LOPEZ JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE STE 300
CONYERS GA
30012-3877
US

IV. Provider business mailing address

2001 PEACHTREE RD NE STE 645
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-918-2320
  • Fax: 833-605-2563
Mailing address:
  • Phone: 404-482-9325
  • Fax: 883-605-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-NP249427
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberAPRN-NP249427
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: