Provider Demographics
NPI:1396011151
Name:LOPEZ, MAX RAUL
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:RAUL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-2869
Mailing Address - Fax:601-815-9356
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS23895208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05339035Medicaid
MSP01551497Medicare PIN
MS428238YJ5DMedicare PIN