Provider Demographics
NPI:1659688018
Name:NAZARIO-LOPEZ, BERNADETTE (MD, PHARMD)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:NAZARIO-LOPEZ
Suffix:
Gender:F
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 W FAIRBANKS AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4679
Mailing Address - Country:US
Mailing Address - Phone:407-303-6729
Mailing Address - Fax:407-628-2037
Practice Address - Street 1:1573 W FAIRBANKS AVE STE 210
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4679
Practice Address - Country:US
Practice Address - Phone:407-303-6729
Practice Address - Fax:407-628-2037
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5083183500000X
PR184582084N0400X
FLME1257992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016257000Medicaid
FLIK996ZMedicare PIN