Healthcare Provider Details

I. General information

NPI: 1770505984
Provider Name (Legal Business Name): MANUEL ANTONIO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18322 SONTERRA PL STE 107
SAN ANTONIO TX
78258-4196
US

IV. Provider business mailing address

PO BOX 591819 STE 5104
SAN ANTONIO TX
78259-0140
US

V. Phone/Fax

Practice location:
  • Phone: 830-328-4206
  • Fax: 210-966-9106
Mailing address:
  • Phone: 210-495-5771
  • Fax: 210-495-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberM2695
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberM2695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: