Provider Demographics
NPI:1306580576
Name:LOPEZ, JORGE LUIS
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ANHALT DR # 50B
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-6110
Mailing Address - Country:US
Mailing Address - Phone:915-240-0866
Mailing Address - Fax:
Practice Address - Street 1:12702 TOEPPERWEIN RD STE 120
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3208
Practice Address - Country:US
Practice Address - Phone:210-653-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist