Provider Demographics
NPI:1063531473
Name:LOPEZ, CARLOS ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE STE 182
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4675
Mailing Address - Country:US
Mailing Address - Phone:407-303-2030
Mailing Address - Fax:
Practice Address - Street 1:680 PEACHWOOD DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0902
Practice Address - Country:US
Practice Address - Phone:386-943-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV122742085R0001X
FLME1076632085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1063531473Medicaid
NV105050Medicare PIN