Healthcare Provider Details

I. General information

NPI: 1336541184
Provider Name (Legal Business Name): THOMAS LOPEZ I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TOMAS R LOPEZ I M.A.

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 EDITH BLVD NE
ALBUQUERQUE NM
87107-2222
US

IV. Provider business mailing address

PO BOX 33922
SANTA FE NM
87594-3922
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-4259
  • Fax: 505-841-4314
Mailing address:
  • Phone: 505-310-0097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number319419
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: