Provider Demographics
NPI:1104131770
Name:LOPEZ VAZQUEZ, MANUEL (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:LOPEZ VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-922-7000
Mailing Address - Fax:210-271-7208
Practice Address - Street 1:5542 WALZEM RD
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78218-2103
Practice Address - Country:US
Practice Address - Phone:210-922-7000
Practice Address - Fax:210-590-8970
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-08
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXQ7412207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX506647YMR2Medicare PIN