Provider Demographics
NPI:1285699199
Name:LOPEZ, JOSEPHINE T (MD)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:T
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:V
Other - Last Name:TICSAY-LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:BLDG 100
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2179
Mailing Address - Country:US
Mailing Address - Phone:706-543-9899
Mailing Address - Fax:706-613-3995
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:BLDG 100
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-543-9899
Practice Address - Fax:706-613-3995
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000754839BMedicaid
GA000754839BMedicaid