Healthcare Provider Details

I. General information

NPI: 1013262377
Provider Name (Legal Business Name): ROSSANA LOPEZ MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 07/23/2012
Certification Date: ROSSANA LOPEZ MD PA 3511 SW 100TH AVE MIAMI FL 33165 777 E 25TH ST HIALEAH FL 33013
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E 25TH ST SUITE 516
HIALEAH FL
33013-3825
US

IV. Provider business mailing address

3511 SW 100TH AVE
MIAMI FL
33165-3846
US

V. Phone/Fax

Practice location:
  • Phone: 305-836-1696
  • Fax: 305-836-1698
Mailing address:
  • Phone: 305-836-1696
  • Fax: 305-647-2150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry
License NumberME64156
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine
License NumberME64156
License Number StateFL

VIII. Authorized Official

Name: DR. ROSSANA LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 305-836-1696