Provider Demographics
NPI:1558568816
Name:LOPEZ, MAYRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MAYRA
Other - Middle Name:
Other - Last Name:LOPEZ MUNIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8904 W HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2726
Mailing Address - Country:US
Mailing Address - Phone:813-509-8083
Mailing Address - Fax:
Practice Address - Street 1:4600 N HABANA AVE STE 32
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7123
Practice Address - Country:US
Practice Address - Phone:813-997-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16817207R00000X
FLACN469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009081300Medicaid
FLPENDINGMedicaid
FLPENDINGMedicare PIN