Provider Demographics
NPI:1982652657
Name:LOPEZ, JORGE IVAN (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:IVAN
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 1:1600 MEDICAL CENTER DR STE B500
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3655
Mailing Address - Country:US
Mailing Address - Phone:304-691-1787
Mailing Address - Fax:304-691-8711
Practice Address - Street 1:1600 MEDICAL CENTER DR STE B500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3655
Practice Address - Country:US
Practice Address - Phone:304-691-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL174402084N0400X, 2084N0402X
WV286282084N0400X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051596437OtherBCBS
AL051596435OtherBCBS
AL107325Medicaid
AL107326Medicaid
AL051113410OtherBCBS
AL125428Medicaid
ALP00720170OtherRAILROAD MEDICARE
AL051596439OtherBCBS
AL107327Medicaid
ALP00720170OtherRAILROAD MEDICARE
AL051596439OtherBCBS