MEDICARE: DANIEL L LOPEZ PH.D.

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	103TC0700X	Clinical Psychologist	24076	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GO3C	OTHER	TX	BCBS
2	276574	OTHER	TX	VALUE OPTIONS
3	0004625076	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1336288257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL L LOPEZ PH.D.

Provider Business Mailing Address
First Line	:	5625 BROADWAY ST
Second Line	:	SUITE 1
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5719
Country	:	US
Telephone Number	:	210-822-7321
Fax Number	:	210-736-1867

Provider Business Practice Location Address
First Line	:	5625 BROADWAY ST
Second Line	:	SUITE 1
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-5719
Country	:	US
Telephone Number	:	210-822-7321
Fax Number	:	210-736-1867

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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