Healthcare Provider Details

I. General information

NPI: 1124453626
Provider Name (Legal Business Name): TANIA LOPEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7915 83RD AVE
SEBASTIAN FL
32958-3282
US

IV. Provider business mailing address

7915 83RD AVE
SEBASTIAN FL
32958-3282
US

V. Phone/Fax

Practice location:
  • Phone: 772-589-0580
  • Fax: 877-291-0858
Mailing address:
  • Phone: 772-589-0580
  • Fax: 877-291-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS12965
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberUO3569
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberML0512965
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS12965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: