Healthcare Provider Details

I. General information

NPI: 1871901793
Provider Name (Legal Business Name): FLORENTINO ALBERTO LUPERCIO LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 300
DAYTONA BEACH FL
32117-5170
US

IV. Provider business mailing address

305 MEMORIAL MEDICAL PKWY STE 300
DAYTONA BEACH FL
32117-5170
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-1023
  • Fax:
Mailing address:
  • Phone: 386-672-1023
  • Fax: 386-263-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberME144467
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME144467
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: