Provider Demographics
NPI:1558632687
Name:CARLOS M LOPEZ MD PA
Entity Type:Organization
Organization Name:CARLOS M LOPEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-861-5765
Mailing Address - Street 1:1133 S.E 18TH PLACE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5410
Mailing Address - Country:US
Mailing Address - Phone:352-861-5765
Mailing Address - Fax:352-867-1801
Practice Address - Street 1:1133 SE 18TH PL
Practice Address - Street 2:SUITE #2
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5410
Practice Address - Country:US
Practice Address - Phone:352-861-5765
Practice Address - Fax:352-867-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE57405Medicare UPIN