Provider Demographics
NPI:1417135997
Name:NELSON LOPEZ MD PA
Entity Type:Organization
Organization Name:NELSON LOPEZ MD PA
Other - Org Name:NELSON LOPEZ MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-734-4535
Mailing Address - Street 1:2609 W WOOLBRIGHT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-6634
Mailing Address - Country:US
Mailing Address - Phone:561-734-4535
Mailing Address - Fax:561-734-7530
Practice Address - Street 1:2609 W WOOLBRIGHT RD
Practice Address - Street 2:SUITE 5
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-6634
Practice Address - Country:US
Practice Address - Phone:561-734-4535
Practice Address - Fax:561-734-7530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027191207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1646OtherMEDICARE PROVIDER