MEDICARE: MARIO J LOPEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MEOO50048	FL
2	207RC0000X	Cardiovascular Disease Physician	ME50048	FL
3	2085R0202X	Diagnostic Radiology Physician	ME50048	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710990882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO J LOPEZ MD

Provider Business Mailing Address
First Line	:	1620 TAMIAMI TRAIL
Second Line	:	SUITE 308
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33948-4017
Country	:	US
Telephone Number	:	941-246-2482
Fax Number	:	941-979-9074

Provider Business Practice Location Address
First Line	:	1620 TAMIAMI TRAIL
Second Line	:	SUITE 308
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33948-4017
Country	:	US
Telephone Number	:	941-246-2482
Fax Number	:	941-979-9074

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	10/31/2025

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Directions to “ MARIO J LOPEZ MD” Practice Location

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