Provider Demographics
NPI:1275581829
Name:LATABAN-LOPEZ, LIDYA MARGARITA (MD)
Entity Type:Individual
Prefix:DR
First Name:LIDYA
Middle Name:MARGARITA
Last Name:LATABAN-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 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-0108
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1914 STATE ROAD 44 STE B
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8345
Practice Address - Country:US
Practice Address - Phone:386-200-4259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15204208D00000X
FLACN911208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22385OtherTRIPLE S DE PUERTO RICO
FLACN911OtherFLORIDA LICENSE
PR9700031OtherHUMANA
PRB159OtherFIRST MEDICAL
PRB159OtherFIRST MEDICAL
FLACN911OtherFLORIDA LICENSE