Healthcare Provider Details

I. General information

NPI: 1508903337
Provider Name (Legal Business Name): IZAIC JOHN HERNANDEZ AR.LOPP,TX.LPOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MADISON OAK DR STE 270
SAN ANTONIO TX
78258-3930
US

IV. Provider business mailing address

16543 CRESTED BUTTE ST
SAN ANTONIO TX
78247-1503
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-3399
  • Fax: 210-495-3393
Mailing address:
  • Phone: 210-264-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number00083
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number00083
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number334
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number00075
License Number State
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0056
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: