Provider Demographics
NPI:1730186362
Name:LOPEZ, SEBASTIAN (MD)
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SEBASTIAN
Other - Middle Name:
Other - Last Name:LOPEZ-FERRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:C/O MSO ADMINISTRATION
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-624-4777
Mailing Address - Fax:575-624-8711
Practice Address - Street 1:601 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5224
Practice Address - Country:US
Practice Address - Phone:575-627-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27867208600000X
NMMD2008-0699208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020043666OtherRR MEDICARE
AZ2Z0574OtherHEALTHNET
AZ479875Medicaid
AZ2214988OtherAETNA
NM36128384Medicaid
AZAZ0850750OtherBLUE CROSS BLUE SHIELD
AZ2Z0574OtherHEALTHNET
28707Medicare ID - Type Unspecified
AZ479875Medicaid