Healthcare Provider Details

I. General information

NPI: 1083708747
Provider Name (Legal Business Name): RAYMOND A LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4064 SW 69TH AVE
MIRAMAR FL
33023-6688
US

IV. Provider business mailing address

16900 NORTH BAY RD 2217
SUNNY ISLES FL
33160-6274
US

V. Phone/Fax

Practice location:
  • Phone: 542-398-8609
  • Fax: 954-239-8847
Mailing address:
  • Phone: 256-508-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME130127
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME130127
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number18239
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME130127
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: