Healthcare Provider Details

I. General information

NPI: 1003973397
Provider Name (Legal Business Name): G. MICHAEL LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MILLS AVE STE 300
LAS VEGAS NM
87701-4169
US

IV. Provider business mailing address

105 MILLS AVE STE 300
LAS VEGAS NM
87701-4169
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-9311
  • Fax: 505-425-9047
Mailing address:
  • Phone: 505-425-9311
  • Fax: 505-425-9047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP-01651
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberNM81-77
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: