Healthcare Provider Details

I. General information

NPI: 1336352772
Provider Name (Legal Business Name): TERCIO LOPES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1378 NW 124TH ST
CLIVE IA
50325-8151
US

IV. Provider business mailing address

1378 NW 124TH ST
CLIVE IA
50325-8151
US

V. Phone/Fax

Practice location:
  • Phone: 515-288-6097
  • Fax:
Mailing address:
  • Phone: 515-288-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number27245
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number104509
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number52288
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number38798
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: