Healthcare Provider Details

I. General information

NPI: 1295646701
Provider Name (Legal Business Name): LOPEZ & CASTILLO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

PO BOX 173
WAYCROSS GA
31502-0173
US

V. Phone/Fax

Practice location:
  • Phone: 201-417-9656
  • Fax: 770-951-2157
Mailing address:
  • Phone: 201-417-9656
  • Fax: 770-951-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERTO JAFET LOPEZ VEGA
Title or Position: OWNER
Credential: MD
Phone: 201-417-9656