Provider Demographics
NPI:1841782505
Name:LOPEZ SURI, DIORGI (APRN)
Entity type:Individual
Prefix:
First Name:DIORGI
Middle Name:
Last Name:LOPEZ SURI
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 SOUTHPOINT DR N STE 107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8026
Mailing Address - Country:US
Mailing Address - Phone:866-372-0308
Mailing Address - Fax:877-460-4651
Practice Address - Street 1:2624 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3609
Practice Address - Country:US
Practice Address - Phone:904-513-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011948363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26778220Medicaid