Provider Demographics
NPI:1881612026
Name:LOPEZ, VICENTE G (MD)
Entity type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:G
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 W FLAGLER ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-6002
Mailing Address - Country:US
Mailing Address - Phone:305-553-0270
Mailing Address - Fax:305-553-0670
Practice Address - Street 1:8300 W FLAGLER ST STE 210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-6002
Practice Address - Country:US
Practice Address - Phone:305-553-0270
Practice Address - Fax:305-553-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82612208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2622475 00Medicaid
FLH36784Medicare UPIN
FL2622475 00Medicaid