Provider Demographics
NPI:1316167398
Name:LOPEZ, JORGE L (PAC)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 TOWNE LAKE PKWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-1602
Mailing Address - Country:US
Mailing Address - Phone:770-924-5095
Mailing Address - Fax:770-924-7429
Practice Address - Street 1:900 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1602
Practice Address - Country:US
Practice Address - Phone:770-924-5095
Practice Address - Fax:770-924-7429
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101712363A00000X
GA005841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I971451Medicare PIN