Healthcare Provider Details

I. General information

NPI: 1144759952
Provider Name (Legal Business Name): MICHELLE LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33607-6214
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 813-875-3950
  • Fax: 813-872-2741
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME157801
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME157801
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: