Provider Demographics
NPI:1003104027
Name:GALLEGOS LOPEZ, LUCY ROCIO (MD)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:ROCIO
Last Name:GALLEGOS LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:ROCIO
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1701 NE MIAMI GARDENS DR APT 117
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5342
Mailing Address - Country:US
Mailing Address - Phone:973-666-5487
Mailing Address - Fax:
Practice Address - Street 1:10725 NW 58TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2801
Practice Address - Country:US
Practice Address - Phone:305-629-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200219207Q00000X
FLME121337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine