Healthcare Provider Details

I. General information

NPI: 1801278999
Provider Name (Legal Business Name): MATIAS SEBASTIAN LOPEZ CHACON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N 30TH ST
OMAHA NE
68131-2136
US

IV. Provider business mailing address

555 N 30TH ST
OMAHA NE
68131-2136
US

V. Phone/Fax

Practice location:
  • Phone: 531-355-6540
  • Fax:
Mailing address:
  • Phone: 531-355-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125067485
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33787
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number33787
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: