Provider Demographics
NPI:1881213247
Name:LOPEZ GONZALEZ, ANILIN
Entity Type:Individual
Prefix:
First Name:ANILIN
Middle Name:
Last Name:LOPEZ GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W 30TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5051
Mailing Address - Country:US
Mailing Address - Phone:786-523-6263
Mailing Address - Fax:
Practice Address - Street 1:805 W 30TH ST APT 11
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5051
Practice Address - Country:US
Practice Address - Phone:786-523-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-006489363A00000X
PR000288-PA363A00000X
NJNJDCATEMP-006503208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty