Provider Demographics
NPI:1629231980
Name:LOPEZ, LIDICE (PA)
Entity Type:Individual
Prefix:
First Name:LIDICE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5317
Mailing Address - Country:US
Mailing Address - Phone:305-528-0447
Mailing Address - Fax:305-466-3223
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:305-545-6685
Practice Address - Fax:305-565-6687
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant