Provider Demographics
NPI:1225210685
Name:LOPEZ GONZALEZ, JUAN PABLO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:PABLO
Last Name:LOPEZ GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34490 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGE MANOR
Mailing Address - State:FL
Mailing Address - Zip Code:33523-8908
Mailing Address - Country:US
Mailing Address - Phone:352-583-4520
Mailing Address - Fax:
Practice Address - Street 1:34490 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:RIDGE MANOR
Practice Address - State:FL
Practice Address - Zip Code:33523-8908
Practice Address - Country:US
Practice Address - Phone:352-583-4520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16911208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16911OtherMEDICINE LICENSE