Healthcare Provider Details

I. General information

NPI: 1952406746
Provider Name (Legal Business Name): GUSTAVO A LOPERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE SUITE 4062
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1500 NW 12TH AVE # EAST1007
MIAMI FL
33136-1051
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-5060
  • Fax:
Mailing address:
  • Phone: 305-243-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME78572
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberME78572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: