Provider Demographics
NPI:1194714196
Name:LOPEZ, JESSE G (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:G
Last Name:LOPEZ
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 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:614-544-6366
Mailing Address - Fax:614-544-6350
Practice Address - Street 1:4605 E ELWOOD ST STE 500
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-1978
Practice Address - Country:US
Practice Address - Phone:602-200-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086107207L00000X
AZ64389207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology