Provider Demographics
NPI:1124006358
Name:LOPEZ, RAFAEL ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ROBERTO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:3347 STATE ROAD 7
Practice Address - Street 2:SUITE 101
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8095
Practice Address - Country:US
Practice Address - Phone:561-790-2111
Practice Address - Fax:561-790-0893
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58240208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1249241OtherWELLCARE
FL4200237OtherAETNA
FL1004922OtherCAREPLUS
FL11453OtherBCBS
FL7851OtherDIMENSION HEALTH
FLP01606329OtherRR MEDICARE
FL064063800Medicaid
FL7851OtherDIMENSION HEALTH
FLP01606329OtherRR MEDICARE
FL064063800Medicaid