MEDICARE: JORGE IVAN LOPEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	17440	AL
2	2084N0400X	Neurology Physician	28628	WV
3	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	17440	AL
4	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	28628	WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	P00720170	OTHER	AL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051596437	OTHER	AL	BCBS
2	051596435	OTHER	AL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	051113410	OTHER	AL	BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	051596439	OTHER	AL	BCBS
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982652657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE IVAN LOPEZ MD

Provider Business Mailing Address
First Line	:	1600 MEDICAL CENTER DR STE B500
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-3655
Country	:	US
Telephone Number	:	304-691-1787
Fax Number	:	304-691-8711

Provider Business Practice Location Address
First Line	:	1600 MEDICAL CENTER DR STE B500
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-3655
Country	:	US
Telephone Number	:	304-691-1787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	11/24/2021

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Directions to “ JORGE IVAN LOPEZ MD” Practice Location

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