Provider Demographics
NPI:1356482426
Name:LOPEZ, KEVIN GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GERARD
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:PO BOX 6880
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-6880
Mailing Address - Country:US
Mailing Address - Phone:505-216-0332
Mailing Address - Fax:505-982-0279
Practice Address - Street 1:4710 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2155
Practice Address - Country:US
Practice Address - Phone:505-955-9454
Practice Address - Fax:505-888-9644
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36573207Q00000X
NMMD2020-0934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51507307Medicaid
AZZ175020Medicare PIN
AZZ122928Medicare PIN
AZI72374Medicare UPIN