Healthcare Provider Details

I. General information

NPI: 1174521983
Provider Name (Legal Business Name): TIMOTHY M LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490A W ZIA RD
SANTA FE NM
87505-6996
US

IV. Provider business mailing address

490A W ZIA RD
SANTA FE NM
87505-6996
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-8900
  • Fax: 505-913-8923
Mailing address:
  • Phone: 505-913-8900
  • Fax: 505-913-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number90-72
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: