Provider Demographics
NPI:1457491714
Name:LOPEZ, RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12424 BRANTLEY COMMONS CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5680
Mailing Address - Country:US
Mailing Address - Phone:239-332-8009
Mailing Address - Fax:239-332-4977
Practice Address - Street 1:2180 W 1ST ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3222
Practice Address - Country:US
Practice Address - Phone:239-332-8009
Practice Address - Fax:239-332-4977
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69037103G00000X, 2084P0800X
VAME690372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251555500Medicaid
D77772Medicare UPIN