Provider Demographics
NPI:1346625746
Name:LOPEZ-FRAGOSO, GRISELL (MD)
Entity Type:Individual
Prefix:DR
First Name:GRISELL
Middle Name:
Last Name:LOPEZ-FRAGOSO
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 1:6674 NW 57 STREET
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-3144
Mailing Address - Country:US
Mailing Address - Phone:954-334-3121
Mailing Address - Fax:954-637-1043
Practice Address - Street 1:6674 NW 57 STREET
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-3144
Practice Address - Country:US
Practice Address - Phone:954-334-3121
Practice Address - Fax:954-637-1043
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19938208D00000X
FL1400208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice