Provider Demographics
NPI:1508881889
Name:LOPEZ-IVERN, FERNANDO M (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:M
Last Name:LOPEZ-IVERN
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 1:9980 CENTRAL PARK BLVD N
Mailing Address - Street 2:SUITE 116
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1762
Mailing Address - Country:US
Mailing Address - Phone:561-893-0651
Mailing Address - Fax:561-893-0655
Practice Address - Street 1:9980 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 116
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1762
Practice Address - Country:US
Practice Address - Phone:561-893-0651
Practice Address - Fax:561-893-0655
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 37131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040420900Medicaid
FL95793ZMedicare PIN
FLD27909Medicare UPIN