Provider Demographics
NPI:1215991914
Name:LOPEZ, LEONARDO VICENTE (MD)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:VICENTE
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 1:2601 SW 37TH AVE
Mailing Address - Street 2:SUITE 701
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2700
Mailing Address - Country:US
Mailing Address - Phone:305-446-7472
Mailing Address - Fax:305-446-6818
Practice Address - Street 1:2601 SW 37TH AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2700
Practice Address - Country:US
Practice Address - Phone:305-446-7472
Practice Address - Fax:305-446-6818
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21513207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058695100Medicaid
78918Medicare ID - Type Unspecified
FL058695100Medicaid