Healthcare Provider Details

I. General information

NPI: 1649662073
Provider Name (Legal Business Name): NICHOLAS LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-5700
  • Fax: 503-418-5704
Mailing address:
  • Phone: 503-418-5700
  • Fax: 503-418-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML60864368
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberMD219244
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD219244
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: