Provider Demographics
NPI:1518187590
Name:LOPEZ, GUILLERMO R (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:R
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 1:9950 SW 107TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-2767
Mailing Address - Country:US
Mailing Address - Phone:305-274-8779
Mailing Address - Fax:052-740-6463
Practice Address - Street 1:9950 SW 107TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2767
Practice Address - Country:US
Practice Address - Phone:305-274-8779
Practice Address - Fax:305-274-0646
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43689ZMedicare PIN
FLG93594Medicare UPIN