Provider Demographics
NPI:1821067851
Name:SERRANO-LOPEZ, CARMEN A (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:A
Last Name:SERRANO-LOPEZ
Suffix:
Gender:F
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:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-615-4015
Mailing Address - Fax:
Practice Address - Street 1:740 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4901
Practice Address - Country:US
Practice Address - Phone:386-763-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74936173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME74936OtherVHN
FLME74936OtherDCWO
FLME74936OtherUNITED BENNEFITS
FLME74936OtherVHN
FL44783ZMedicare PIN