Basic Information
Provider Information
NPI: 1003298928
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOPEZ
FirstName: ELENA
MiddleName: M
NamePrefix:  
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3005 FOUNTAIN DR
Address2:  
City: CONWAY
State: AR
PostalCode: 720343684
CountryCode: US
TelephoneNumber: 5013299851
FaxNumber:  
Practice Location
Address1: 3005 FOUNTAIN DR
Address2:  
City: CONWAY
State: AR
PostalCode: 720343684
CountryCode: US
TelephoneNumber: 5013299851
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/27/2015
LastUpdateDate: 03/23/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X2721ARY Eye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
21016872205AR MEDICAID


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