Healthcare Provider Details

I. General information

NPI: 1922757558
Provider Name (Legal Business Name): LOPEZ FAMILY PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 SOUTHPOINT DR N STE 107
JACKSONVILLE FL
32216-8026
US

IV. Provider business mailing address

6821 SOUTHPOINT DR N STE 107
JACKSONVILLE FL
32216-8026
US

V. Phone/Fax

Practice location:
  • Phone: 904-862-6070
  • Fax: 904-595-3767
Mailing address:
  • Phone: 904-862-6070
  • Fax: 904-595-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIORGI LOPEZ SURI
Title or Position: OWNER
Credential: APRN
Phone: 904-862-6070