Healthcare Provider Details

I. General information

NPI: 1730174319
Provider Name (Legal Business Name): FERNANDO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11399 LAKE UNDERHILL RD
ORLANDO FL
32825-5023
US

IV. Provider business mailing address

1445 BROOKS LN
OVIEDO FL
32765-8624
US

V. Phone/Fax

Practice location:
  • Phone: 407-207-6768
  • Fax: 407-249-5025
Mailing address:
  • Phone: 407-207-6768
  • Fax: 407-249-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME45835
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: