Provider Demographics
NPI:1326159385
Name:LOPEZ, ROSSANA (MD)
Entity Type:Individual
Prefix:
First Name:ROSSANA
Middle Name:
Last Name: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 1:3511 SW 100TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3846
Mailing Address - Country:US
Mailing Address - Phone:305-836-1696
Mailing Address - Fax:305-836-1698
Practice Address - Street 1:600 E 25TH ST STE A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3801
Practice Address - Country:US
Practice Address - Phone:305-836-1696
Practice Address - Fax:305-397-2255
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64156207RG0300X, 2084P0800X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374037400Medicaid
FLF35754Medicare UPIN
FL23291Medicare ID - Type Unspecified