Provider Demographics
NPI:1275561219
Name:LOPEZ, JUAN ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ALBERT
Last Name:LOPEZ
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 1:1616 WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4142
Mailing Address - Country:US
Mailing Address - Phone:407-896-1181
Mailing Address - Fax:407-898-1623
Practice Address - Street 1:1616 WOODWARD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4142
Practice Address - Country:US
Practice Address - Phone:407-896-1181
Practice Address - Fax:407-898-1623
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59006208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340004768OtherRAILROAD MEDICARE
FL053348300Medicaid
340004768OtherRAILROAD MEDICARE
FL053348300Medicaid