Provider Demographics
NPI:1124453626
Name:LOPEZ, TANIA (DO)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7915 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3282
Mailing Address - Country:US
Mailing Address - Phone:772-589-0580
Mailing Address - Fax:877-291-0858
Practice Address - Street 1:7915 83RD AVE
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3282
Practice Address - Country:US
Practice Address - Phone:772-589-0580
Practice Address - Fax:877-291-0858
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12965207R00000X, 207RG0100X
FLUO3569207R00000X
FLML0512965207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106666600Medicaid
FL0137977-00Medicaid