Provider Demographics
NPI:1710990882
Name:LOPEZ, MARIO J (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2484 CARING WAY
Mailing Address - Street 2:UNIT F
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5306
Mailing Address - Country:US
Mailing Address - Phone:941-246-2482
Mailing Address - Fax:941-979-9074
Practice Address - Street 1:2484 CARING WAY
Practice Address - Street 2:UNIT F
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5306
Practice Address - Country:US
Practice Address - Phone:941-246-2482
Practice Address - Fax:941-979-9074
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-05-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLMEOO50048174400000X
FLME500482085R0202X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046520800Medicaid
FL046520800Medicaid
FL02784WMedicare ID - Type Unspecified