Basic Information
Provider Information | |||||||||
NPI: | 1316037005 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOPEZ | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2605 KENTUCKY AVE | ||||||||
Address2: | SUITE 306 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420033800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704157653 | ||||||||
FaxNumber: | 2075758359 | ||||||||
Practice Location | |||||||||
Address1: | 2601 KENTUCKY AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420033817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704435564 | ||||||||
FaxNumber: | 2704435549 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 42975 | KY | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 64113764 | 05 | KY |   | MEDICAID |