Healthcare Provider Details

I. General information

NPI: 1114348653
Provider Name (Legal Business Name): JORGE LOPEZ NMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 E SOUTHERN AVE STE 3
TEMPE AZ
85282-7666
US

IV. Provider business mailing address

2501 E SOUTHERN AVE STE 3
TEMPE AZ
85282-7666
US

V. Phone/Fax

Practice location:
  • Phone: 602-492-7127
  • Fax: 877-749-8607
Mailing address:
  • Phone: 602-770-9416
  • Fax: 877-749-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNP416
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number13-1414
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: