Provider Demographics
NPI:1003973397
Name:LOPEZ, G. MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:G. MICHAEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MILLS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4169
Mailing Address - Country:US
Mailing Address - Phone:505-425-9311
Mailing Address - Fax:505-425-9047
Practice Address - Street 1:105 MILLS AVE STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4169
Practice Address - Country:US
Practice Address - Phone:505-425-9311
Practice Address - Fax:505-425-9047
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM81-77207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201006000OtherPRESBYTERIAN HEALTH PLAN
NM50013OtherHMO OF NEW MEXICO
NMNM00007070Medicaid
NM1991OtherLOVELACE
NMNM001568OtherBLUE CROSS BLUE SHIELD
NM201006000OtherPRESBYTERIAN HEALTH PLAN
NMNM001568OtherBLUE CROSS BLUE SHIELD