Provider Demographics
NPI:1770538605
Name:LOPEZ, MARISA P (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:P
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:PREGO LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9960 NW 116TH WAY STE 13
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1175
Mailing Address - Country:US
Mailing Address - Phone:786-924-1311
Mailing Address - Fax:786-924-1313
Practice Address - Street 1:1330 SE 4TH AVE STE J
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-620-3307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME907852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269970200Medicaid
FL47480WMedicare PIN
FL47480VMedicare PIN
FL269970200Medicaid