Healthcare Provider Details

I. General information

NPI: 1316471303
Provider Name (Legal Business Name): MIGUEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7000
  • Fax:
Mailing address:
  • Phone: 318-626-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number338082
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number338082
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: