Healthcare Provider Details

I. General information

NPI: 1801158969
Provider Name (Legal Business Name): MARVIN A LOPEZ MEDAL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 SOUTHERN BLVD
LOXAHATCHEE FL
33470-9203
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 877-832-2652
  • Fax: 800-792-9021
Mailing address:
  • Phone: 877-832-2652
  • Fax: 800-792-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME123271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: