Basic Information
Provider Information | |||||||||
NPI: | 1457379935 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOPEZ | ||||||||
FirstName: | AMANTE | ||||||||
MiddleName: | AGUSTIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 327 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | BRIDGEPORT | ||||||||
State: | WV | ||||||||
PostalCode: | 263309006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6813421000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 327 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | BRIDGEPORT | ||||||||
State: | WV | ||||||||
PostalCode: | 263309006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6813421610 | ||||||||
FaxNumber: | 6813421626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 01/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 16170 | WV | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 001720948 | 01 | WV | MOUNTAIN STATE BCBS | OTHER | 229645 | 01 |   | CARELINK | OTHER | WV16170 | 01 |   | HEALTH PLAN | OTHER | 0059024000 | 05 | WV |   | MEDICAID |