Provider Demographics
NPI:1891925848
Name:G MICHAEL LOPEZ
Entity Type:Organization
Organization Name:G MICHAEL LOPEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:G MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-425-9311
Mailing Address - Street 1:105 MILLS AVE # 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM81-770207R00000X
NM92PA09363A00000X
NMR53421363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM001568OtherBLUE CROSS BLUE SHIELD
NM201006000OtherPRESBYTERIAN HEALTH PLAN
NM00007070Medicaid
NMNM001568OtherBLUE CROSS BLUE SHIELD
NM001568OtherBLUE CROSS BLUE SHIELD
NM201006000OtherPRESBYTERIAN HEALTH PLAN