Provider Demographics
NPI:1720843162
Name:LOPEZ, MARCO ANTONIO (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 SURREY CIR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-6325
Mailing Address - Country:US
Mailing Address - Phone:469-951-4105
Mailing Address - Fax:
Practice Address - Street 1:18601 LYNDON B JOHNSON FWY STE 116
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5629
Practice Address - Country:US
Practice Address - Phone:972-270-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13884692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic