Provider Demographics
NPI:1003071945
Name:LOPEZ DA RE, JORGE MARTIN (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MARTIN
Last Name:LOPEZ DA RE
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 1:1500 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6504
Mailing Address - Country:US
Mailing Address - Phone:407-303-2528
Mailing Address - Fax:407-303-2760
Practice Address - Street 1:1500 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:407-303-2528
Practice Address - Fax:407-303-2760
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0071739208000000X
FLME1087632080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics