Healthcare Provider Details

I. General information

NPI: 1104841238
Provider Name (Legal Business Name): SERGIO LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 45TH ST
WEST PALM BEACH FL
33407-2361
US

IV. Provider business mailing address

1150 45TH ST
WEST PALM BEACH FL
33407-2361
US

V. Phone/Fax

Practice location:
  • Phone: 561-514-5300
  • Fax: 561-514-5540
Mailing address:
  • Phone: 561-514-5300
  • Fax: 561-837-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME71762
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: