Healthcare Provider Details

I. General information

NPI: 1699161133
Provider Name (Legal Business Name): JENNIFER R LOPEZ LOPEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 12/06/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W OAK ST
KISSIMMEE FL
34741-4924
US

IV. Provider business mailing address

8133 TOPSAIL PL
WINTER GARDEN FL
34787-4581
US

V. Phone/Fax

Practice location:
  • Phone: 407-520-3947
  • Fax:
Mailing address:
  • Phone: 787-718-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number146317
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number146317
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number146317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: