Provider Demographics
NPI:1558660167
Name:VICTOR LOPEZ DE MENDOZA, MD PLLC
Entity Type:Organization
Organization Name:VICTOR LOPEZ DE MENDOZA, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOPEZ DE MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-448-0004
Mailing Address - Street 1:PO BOX 651472
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33265-1472
Mailing Address - Country:US
Mailing Address - Phone:305-480-6864
Mailing Address - Fax:
Practice Address - Street 1:1321 NW 14TH ST
Practice Address - Street 2:STE 603
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1673
Practice Address - Country:US
Practice Address - Phone:305-547-1444
Practice Address - Fax:305-547-6787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICTOR LOPEZ DE MENDOZA MD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-22
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105859207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003708700Medicaid
FL003708700Medicaid