Provider Demographics
NPI:1124088133
Name:LOPEZ, MARIA I (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:I
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MEMORIAL CIRCLE
Mailing Address - Street 2:UNIT N
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-615-8909
Mailing Address - Fax:386-615-8910
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 303
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5168
Practice Address - Country:US
Practice Address - Phone:386-615-8909
Practice Address - Fax:386-615-8910
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266162400Medicaid
FLME86776OtherUNITED BENEFITS
FLME86776OtherDCWO
FLME86776OtherVHN
FLME86776OtherDCWO
FL266162400Medicaid