MEDICARE: DR. ANGEL LUIS LOPEZ DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	0560	TX

General Provider Information

NPI Number	:	1245328590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGEL LUIS LOPEZ DPM

Provider Business Mailing Address
First Line	:	910 W NORTHSIDE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-9046
Country	:	US
Telephone Number	:	817-625-1103
Fax Number	:	817-625-7425

Provider Business Practice Location Address
First Line	:	910 W NORTHSIDE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76106-9046
Country	:	US
Telephone Number	:	817-625-1103
Fax Number	:	817-625-7425

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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