Provider Demographics
NPI:1104935329
Name:LOPEZ-AGUADO, JORGE (MD/)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:LOPEZ-AGUADO
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:PO BOX 2588
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:CA
Mailing Address - Zip Code:93644-2588
Mailing Address - Country:US
Mailing Address - Phone:559-683-2459
Mailing Address - Fax:
Practice Address - Street 1:49430 ROAD 426
Practice Address - Street 2:SUITE B
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-8618
Practice Address - Country:US
Practice Address - Phone:559-683-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF39744208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G633330Medicaid
F39744Medicare UPIN
CA00G633330Medicaid