MEDICARE: JOEL LOPEZ

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	163W00000X	Registered Nurse	95155507	CA
2	363LF0000X	Family Nurse Practitioner	95023964	CA

General Provider Information

NPI Number	:	1104391200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL LOPEZ

Provider Business Mailing Address
First Line	:	3454 DEL REY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5752
Country	:	US
Telephone Number	:	619-995-0303
Fax Number	:

Provider Business Practice Location Address
First Line	:	5562 PHILADELPHIA ST STE 301
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2499
Country	:	US
Telephone Number	:	214-868-4371
Fax Number	:

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

Provider Enumeration Date	:	10/04/2018
Last Update Date	:	03/30/2023

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Directions to “ JOEL LOPEZ ” Practice Location

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