Provider Demographics
NPI:1831347251
Name:LOPEZ, LEONARDO E JR (MD)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:E
Last Name:LOPEZ
Suffix:JR
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 1:203 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2012
Mailing Address - Country:US
Mailing Address - Phone:575-303-3692
Mailing Address - Fax:
Practice Address - Street 1:203 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2012
Practice Address - Country:US
Practice Address - Phone:575-303-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0182207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82527369Medicaid
NM284002YMIKMedicare PIN