Provider Demographics
NPI:1083590020
Name:LOPEZ, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HEALTH SCIENCES CENTER, MSC09 5300,
Mailing Address - Street 2:1 UNIVERSITY OF NEW MEXICO, ALBUQUERQUE,
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131
Mailing Address - Country:US
Mailing Address - Phone:505-272-5849
Mailing Address - Fax:
Practice Address - Street 1:2500 MARBLE AVE N.E
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-272-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1804172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker