Provider Demographics
NPI:1568450617
Name:LOPEZ, MARIA V (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:V
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:VICTORIA
Other - Last Name:LOPEZ DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2115 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8815
Mailing Address - Country:US
Mailing Address - Phone:727-526-9135
Mailing Address - Fax:
Practice Address - Street 1:12170 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-2833
Practice Address - Country:US
Practice Address - Phone:727-586-5355
Practice Address - Fax:727-586-6997
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81536208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010564800Medicaid