Healthcare Provider Details

I. General information

NPI: 1174560619
Provider Name (Legal Business Name): ID PROFESSIONALS OF SOUTH FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W 49TH ST SUITE 400-9
HIALEAH FL
33012-2992
US

IV. Provider business mailing address

PO BOX 371082
MIAMI FL
33137-1082
US

V. Phone/Fax

Practice location:
  • Phone: 305-698-5997
  • Fax: 305-698-5998
Mailing address:
  • Phone: 305-698-5997
  • Fax: 305-698-5998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME75291
License Number StateFL

VIII. Authorized Official

Name: DR. MARIO R. LOPEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-495-5102