Healthcare Provider Details

I. General information

NPI: 1063531473
Provider Name (Legal Business Name): CARLOS ALBERTO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 PEACHWOOD DR
DELAND FL
32720-0902
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 182
ORLANDO FL
32804-4675
US

V. Phone/Fax

Practice location:
  • Phone: 386-943-7160
  • Fax:
Mailing address:
  • Phone: 407-303-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number12274
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME107663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: