Provider Demographics
NPI:1396704821
Name:LOPEZ, RUBEN J (MD)
Entity type:Individual
Prefix:
First Name:RUBEN
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1728 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8929
Mailing Address - Country:US
Mailing Address - Phone:386-322-5390
Mailing Address - Fax:386-322-5391
Practice Address - Street 1:1728 DUNLAWTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8929
Practice Address - Country:US
Practice Address - Phone:386-322-5390
Practice Address - Fax:386-322-5391
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2022-01-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL68668208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME68668OtherVHN
FL250201100Medicaid
FL31712OtherBCBS
FLME0068668OtherDCWO
FLME68668OtherUNITED BENEFITS
FL31712OtherBCBS
FLG30967Medicare UPIN