Basic Information
| Provider Information | |||||||||
| NPI: | 1316144728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | NEUROLOGY, MB.7.420 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872078 | ||||||||
| FaxNumber: | 2069872649 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | NEUROLOGY, MB.7.420 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872078 | ||||||||
| FaxNumber: | 2069872649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | MD 60476381 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0600X | MD 60476381 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | G8933624 | 01 | MEDICARE | OTHER | G89336323 | 01 | MEDICARE | OTHER | 1622251 | 05 | AK | MEDICAID |