Healthcare Provider Details

I. General information

NPI: 1336352806
Provider Name (Legal Business Name): JOSE LUIS LOPEZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 N MAIN ST STE 100
GRANGER IN
46530-8039
US

IV. Provider business mailing address

3245 HEALTH DRIVE SUITE 100
GRANGER IN
46530-3245
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-8542
  • Fax: 574-647-8549
Mailing address:
  • Phone: 574-647-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01073464A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier201214240
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: