Healthcare Provider Details

I. General information

NPI: 1316913171
Provider Name (Legal Business Name): IVELISSE LOPEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 310
FORT WAYNE IN
46845-1733
US

IV. Provider business mailing address

2880 S OSCEOLA AVE
ORLANDO FL
32806-5431
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5230
  • Fax: 260-458-5972
Mailing address:
  • Phone: 407-843-0443
  • Fax: 407-843-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME82595
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01100291A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: