Provider Demographics
NPI:1104841238
Name:LOPEZ, SERGIO (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 45TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2361
Mailing Address - Country:US
Mailing Address - Phone:561-514-5300
Mailing Address - Fax:561-837-5332
Practice Address - Street 1:1150 45TH ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2361
Practice Address - Country:US
Practice Address - Phone:561-514-5300
Practice Address - Fax:561-514-5540
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71762207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251507500Medicaid
FL28179AMedicare ID - Type Unspecified
FL251507500Medicaid