Healthcare Provider Details

I. General information

NPI: 1831161132
Provider Name (Legal Business Name): ELENA R LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 W 18TH ST FL 1
CHICAGO IL
60608-1903
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 773-254-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015030335
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC149479
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-104170
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: