Provider Demographics
NPI:1629168497
Name:LOPEZ, IVAN ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:ANTONIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 SE COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-3802
Mailing Address - Country:US
Mailing Address - Phone:386-752-4510
Mailing Address - Fax:
Practice Address - Street 1:1200 NE 55TH BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-2783
Practice Address - Country:US
Practice Address - Phone:352-375-8484
Practice Address - Fax:352-264-8305
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME257862084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology