Provider Demographics
NPI:1316120116
Name:MANUEL D LOPEZ MD PA
Entity type:Organization
Organization Name:MANUEL D LOPEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOPEZ-LEYVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-591-2922
Mailing Address - Street 1:10201 GATEWAY BLVD W
Mailing Address - Street 2:STE 210
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7652
Mailing Address - Country:US
Mailing Address - Phone:915-591-2922
Mailing Address - Fax:
Practice Address - Street 1:10201 GATEWAY BLVD W
Practice Address - Street 2:STE 210
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7652
Practice Address - Country:US
Practice Address - Phone:915-591-2922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z047Medicare PIN