Provider Demographics
NPI:1568492528
Name:LOPEZ, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 NW 82ND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1056
Mailing Address - Country:US
Mailing Address - Phone:305-591-2988
Mailing Address - Fax:305-591-2995
Practice Address - Street 1:3155 NW 82ND AVE STE 102
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1056
Practice Address - Country:US
Practice Address - Phone:305-591-2988
Practice Address - Fax:305-591-2995
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI15498Medicare UPIN
FLU3094ZMedicare ID - Type Unspecified