Provider Demographics
NPI:1831156470
Name:LOPEZ, ASTRID JANNETTE (MD)
Entity type:Individual
Prefix:MS
First Name:ASTRID
Middle Name:JANNETTE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ASTRID
Other - Middle Name:JANNETTE
Other - Last Name:LOPEZ-CORREA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:866-234-8534
Mailing Address - Fax:863-837-4441
Practice Address - Street 1:201 MAGNOLIA AVE SW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-2943
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:863-837-4441
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10007949208000000X
PR13544208000000X
FLME98788208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01390000OtherAMERIGROUP
FL148FZOtherBC/BS
FL281178200Medicaid
PRB1510OtherTRIPLE SSS
FL51807OtherCIGNA
FL81178200Medicaid