Provider Demographics
NPI:1659391951
Name:LOPEZ, FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
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:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1245
Mailing Address - Country:US
Mailing Address - Phone:334-712-2720
Mailing Address - Fax:334-712-2727
Practice Address - Street 1:134 PREVATT RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5427
Practice Address - Country:US
Practice Address - Phone:334-794-0731
Practice Address - Fax:334-671-9199
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL64362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937156Medicaid
AL051000547OtherSPS - BCBS
AL009934129Medicaid
AL009979915Medicaid
AL051000544OtherOSC - BCBS
AL051533769OtherEBHS - BCBS
AL051533770OtherTROY - BCBS
AL009979055Medicaid
AL051000544OtherOSC - BCBS
AL009979915Medicaid
AL009934129Medicaid
AL051555393Medicare ID - Type UnspecifiedOSC