Healthcare Provider Details

I. General information

NPI: 1760470306
Provider Name (Legal Business Name): IVAN D. LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IVAN D. LOPEZ M.D.

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 SW 13TH ST
GAINESVILLE FL
32608-4006
US

IV. Provider business mailing address

439 SW MICHIGAN ST
LAKE CITY FL
32025-0440
US

V. Phone/Fax

Practice location:
  • Phone: 352-374-5600
  • Fax:
Mailing address:
  • Phone: 386-487-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number24227
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number24227
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME108228
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: