Provider Demographics
NPI:1275639544
Name:LOPEZ, WILBERTO L (MD)
Entity Type:Individual
Prefix:DR
First Name:WILBERTO
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:910 WILLISTON PARK PT
Mailing Address - Street 2:STE 1000
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2172
Mailing Address - Country:US
Mailing Address - Phone:407-833-8028
Mailing Address - Fax:407-833-8033
Practice Address - Street 1:910 WILLISTON PARK PT
Practice Address - Street 2:STE 1000
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2172
Practice Address - Country:US
Practice Address - Phone:407-833-8028
Practice Address - Fax:407-833-8033
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 80778207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35761OtherBCBS OF FL
FL35761YMedicare ID - Type Unspecified
FLG93754Medicare UPIN