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1073599619

NPI Code Detail

MEDICARE: MR. ABRAHAM DAGOBERTO LOPEZ JR. PA

MEDICARE: MR. ABRAHAM DAGOBERTO LOPEZ JR. PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	2816	AZ
2	363A00000X	Physician Assistant	2816	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	860373636	OTHER	AZ	HUMANA-GROUP #
3	453051001	OTHER	AZ	GROUP HEALTH GROUP
4	3987220	OTHER	AZ	EYECARE
5	AW1436	OTHER	AZ	HEALTHNET GROUP

General Provider Information

NPI Number	:	1073599619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ABRAHAM DAGOBERTO LOPEZ JR. PA

Provider Business Mailing Address
First Line	:	4518 W PARADISE DR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-3027
Country	:	US
Telephone Number	:	602-320-0580
Fax Number	:	602-354-4171

Provider Business Practice Location Address
First Line	:	5102 W CAMPBELL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-1703
Country	:	US
Telephone Number	:	623-848-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	12/22/2020

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Directions to “ MR. ABRAHAM DAGOBERTO LOPEZ JR. PA” Practice Location

Language	Start Address	Practice Location

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