=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366814568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLORIA LOPEZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2015
-----------------------------------------------------
Last Update Date | 10/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 PONCE DE LEON BLVD STE 603
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-443-2324
-----------------------------------------------------
Fax | 305-290-3180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 747 PONCE DE LEON BLVD STE 603
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-443-2324
-----------------------------------------------------
Fax | 305-290-3180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GLORIA LOPEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-443-2324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 38886
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------