Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | ME71762 | FL |
NPI | 1104841238 |
---|---|
Provider Name | Sergio Lopez |
First Address | West Palm Beach, FL 33407-2361 |
Second Address | West Palm Beach, FL 33407-2361 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 31/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
251507500 | (05) | FL |
G63522 | (02) | FL |