Basic Information
| Provider Information | |||||||||
| NPI: | 1083789952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1440 WESTCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601543631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088658106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1431 N CLAREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732782000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.