Provider Demographics
NPI:1083708747
Name:LOPEZ, RAYMOND A (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:A
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 1:16900 NORTH BAY RD 2217
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES
Mailing Address - State:FL
Mailing Address - Zip Code:33160-6274
Mailing Address - Country:US
Mailing Address - Phone:256-508-9002
Mailing Address - Fax:
Practice Address - Street 1:4064 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-6688
Practice Address - Country:US
Practice Address - Phone:542-398-8609
Practice Address - Fax:954-239-8847
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130127207Q00000X, 207QA0505X, 207V00000X
AL18239207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51097396OtherBLUE CROSS&BLUE SHIELD
ALA64536Medicare UPIN