Provider Demographics
NPI:1336541184
Name:LOPEZ, THOMAS I
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LOPEZ
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TOMAS
Other - Middle Name:R
Other - Last Name:LOPEZ
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 33922
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87594-3922
Mailing Address - Country:US
Mailing Address - Phone:505-310-0097
Mailing Address - Fax:
Practice Address - Street 1:4000 EDITH BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2222
Practice Address - Country:US
Practice Address - Phone:505-841-4259
Practice Address - Fax:505-841-4314
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM319419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist