Provider Demographics
NPI:1881065662
Name:FEDERAL BUREAU OF PRISONS
Entity type:Organization
Organization Name:FEDERAL BUREAU OF PRISONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-689-7332
Mailing Address - Street 1:2801 FALCON RDG
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5892
Mailing Address - Country:US
Mailing Address - Phone:352-243-8998
Mailing Address - Fax:
Practice Address - Street 1:2801 FALCON RDG
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5892
Practice Address - Country:US
Practice Address - Phone:352-243-8998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF JUSTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133531-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty