Provider Demographics
NPI:1710947940
Name:LOPEZ-GUTIERREZ, JOSE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:L
Last Name:LOPEZ-GUTIERREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:L
Other - Last Name:LOPEZ-GUTIERREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8911 DANIELS PKWY STE 7
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-0872
Mailing Address - Country:US
Mailing Address - Phone:239-939-2200
Mailing Address - Fax:239-939-2204
Practice Address - Street 1:8911 DANIELS PKWY STE 7
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-0872
Practice Address - Country:US
Practice Address - Phone:239-939-2200
Practice Address - Fax:239-939-2204
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38626OtherBS GROUP
28726OtherBS INDIV
FL274165200Medicaid
FL28726XMedicare PIN
FL274165200Medicaid
28726OtherBS INDIV
FLK0777Medicare ID - Type UnspecifiedGROUP