Provider Demographics
NPI:1568458891
Name:LOPEZ, BERNARD RONALD (MD)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:RONALD
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RON
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2843 ALTERNATE 19
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683
Mailing Address - Country:US
Mailing Address - Phone:727-772-0038
Mailing Address - Fax:727-787-2384
Practice Address - Street 1:2843 ALTERNATE 19
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683
Practice Address - Country:US
Practice Address - Phone:727-772-0038
Practice Address - Fax:727-787-2384
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME00429562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064226600Medicaid
96363Medicare ID - Type Unspecified
E71305Medicare UPIN