Healthcare Provider Details

I. General information

NPI: 1073892071
Provider Name (Legal Business Name): MARCO A LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 E NOLANA LOOP SUITE A
PHARR TX
78577
US

IV. Provider business mailing address

1402. E. NOLANA LOOP SUITE A
PHARR TX
78577
US

V. Phone/Fax

Practice location:
  • Phone: 956-601-0831
  • Fax: 956-601-0831
Mailing address:
  • Phone: 956-601-0831
  • Fax: 956-601-0831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP0849
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: