Provider Demographics
NPI:1871727347
Name:LOPEZ, CLEA LYNN (MD)
Entity type:Individual
Prefix:
First Name:CLEA
Middle Name:LYNN
Last Name:LOPEZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 HOSPITAL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4794
Mailing Address - Country:US
Mailing Address - Phone:505-670-1976
Mailing Address - Fax:505-983-7212
Practice Address - Street 1:1650 HOSPITAL DR STE 500
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4794
Practice Address - Country:US
Practice Address - Phone:505-670-1976
Practice Address - Fax:505-983-7212
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-1054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79273858Medicaid
ORR171418Medicare PIN