Provider Demographics
NPI:1235494568
Name:LOPEZ TABLAS, JOSE ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ERNESTO
Last Name:LOPEZ TABLAS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2297
Mailing Address - Country:US
Mailing Address - Phone:717-316-3711
Mailing Address - Fax:717-316-3049
Practice Address - Street 1:300 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2297
Practice Address - Country:US
Practice Address - Phone:717-316-3711
Practice Address - Fax:717-316-3049
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD158669208000000X
SC82513208000000X
PAMD450276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics