Provider Demographics
NPI:1891985032
Name:AVILES-LOPEZ, LUIS EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:EDUARDO
Last Name:AVILES-LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3011
Mailing Address - Fax:239-658-3070
Practice Address - Street 1:1454 MADISON AVE W
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2200
Practice Address - Country:US
Practice Address - Phone:239-658-3011
Practice Address - Fax:239-658-3070
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD15467R208000000X
FLME59851208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371593100Medicaid
LA1468134Medicaid
F46332Medicare UPIN