Provider Demographics
NPI:1538293428
Name:LOPEZ, VIRGILIO DIZON (MD)
Entity Type:Individual
Prefix:
First Name:VIRGILIO
Middle Name:DIZON
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 1:4095 WATERVIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-7602
Mailing Address - Country:US
Mailing Address - Phone:407-657-6523
Mailing Address - Fax:
Practice Address - Street 1:5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-8208
Practice Address - Country:US
Practice Address - Phone:407-621-2632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME805472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A332200Medicaid
CAL50555Medicare UPIN
CA00A332200Medicare ID - Type Unspecified