Basic Information
| Provider Information | |||||||||
| NPI: | 1194816140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9247 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319089247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063227884 | ||||||||
| FaxNumber: | 7062434345 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 17TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063227884 | ||||||||
| FaxNumber: | 7062434355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 246 | AL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 1541 | TX | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | E-3603 | CA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 000814 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000750439O | 05 | GA | MEDICAID | 814 | 01 | GA | STATE ID | OTHER | 202I501203 | 01 | GA | MEDICARE PTAN | OTHER |