Healthcare Provider Details

I. General information

NPI: 1053473504
Provider Name (Legal Business Name): JUAN MANUEL LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT EISENHOWER GA
30905-5741
US

IV. Provider business mailing address

300 W HOSPITAL RD
FORT EISENHOWER GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-1164
  • Fax:
Mailing address:
  • Phone: 706-787-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME74668
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number74518
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: