Healthcare Provider Details

I. General information

NPI: 1730186362
Provider Name (Legal Business Name): SEBASTIAN LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SEBASTIAN LOPEZ-FERRES M.D.

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W COUNTRY CLUB RD SUITE 201
ROSWELL NM
88201-5224
US

IV. Provider business mailing address

405 W COUNTRY CLUB RD C/O MSO ADMINISTRATION
ROSWELL NM
88201-5209
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-0535
  • Fax:
Mailing address:
  • Phone: 575-624-4777
  • Fax: 575-624-8711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number27867
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2008-0699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: