Basic Information
| Provider Information | |||||||||
| NPI: | 1073599619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | ABRAHAM | ||||||||
| MiddleName: | DAGOBERTO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4518 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853043027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023200580 | ||||||||
| FaxNumber: | 6023544171 | ||||||||
| Practice Location | |||||||||
| Address1: | 5102 W CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238485000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2816 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | 2816 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 817827 | 05 | AZ | MEDICAID | 860373636 | 01 | AZ | HUMANA-GROUP # | OTHER | 453051001 | 01 | AZ | GROUP HEALTH GROUP | OTHER | 3987220 | 01 | AZ | EYECARE | OTHER | AW1436 | 01 | AZ | HEALTHNET GROUP | OTHER |