Basic Information
| Provider Information | |||||||||
| NPI: | 1235211236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11247 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947122247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109814100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2031 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109814100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 46784 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A54812 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2274032 | 01 | MN | ARAZ | OTHER | 782052 | 01 | MN | FAIRVIEW | OTHER | 132531 | 01 | MN | UCARE | OTHER | 367187900 | 05 | MN | MEDICAID | HP48293 | 01 | MN | HEALTH PARTNERS | OTHER | 935S7LO | 01 | MN | BCBS | OTHER | 01-19261 | 01 | MN | MEDICA-CHOICE | OTHER | 0586909 | 05 | IA | MEDICAID | 1042594 | 01 | MN | PREFERRED ONE | OTHER | 2274032 | 01 | MN | AMERICA'S PPO | OTHER | 34600900 | 05 | WI | MEDICAID |