Provider Demographics
NPI:1124306436
Name:LOPEZ, ROBERTO A (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:1287 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285
Practice Address - Country:US
Practice Address - Phone:941-202-0500
Practice Address - Fax:941-202-0501
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44338207R00000X
FLME135370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJJ033ZOtherMEDICARE
FL9BCIXOtherFLORIDA BLUE
AZ633381Medicaid
FL024695300Medicaid