MEDICARE: SALVADOR LOPEZ JR PHD PC

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	22593	TX

General Provider Information

NPI Number	:	1497199913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALVADOR LOPEZ JR PHD PC

Provider Business Mailing Address
First Line	:	7201 BROADWAY ST
Second Line	:	SUITE 218
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-413-9779
Fax Number	:	210-239-6868

Provider Business Practice Location Address
First Line	:	7201 BROADWAY ST
Second Line	:	SUITE 218
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-3773
Country	:	US
Telephone Number	:	210-413-9779
Fax Number	:	210-239-6868

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SALVADOR LOPEZ JR.
Credential	:	PHD
Telephone Number	:	210-413-9779

Provider Enumeration Date	:	04/26/2013
Last Update Date	:	07/28/2015

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