Provider Demographics
NPI:1235622549
Name:LOPEZ PEREZ, JORGE EDMUNDO (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:EDMUNDO
Last Name:LOPEZ PEREZ
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 1:8255 SW 72ND CT UNIT 429
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4262
Mailing Address - Country:US
Mailing Address - Phone:786-385-7614
Mailing Address - Fax:
Practice Address - Street 1:11750 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3530
Practice Address - Country:US
Practice Address - Phone:305-223-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME147551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program