Basic Information
| Provider Information | |||||||||
| NPI: | 1932688496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | RAUL | ||||||||
| MiddleName: | ANDRES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660482829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875488077 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10127 STATE LINE RD | ||||||||
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| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641144262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167652500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2018 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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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 | 152W00000X | 2018028385 | MO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.