Provider Demographics
NPI:1275581829
Name:LATABAN-LOPEZ, LIDYA MARGARITA (MD)
Entity type:Individual
Prefix:DR
First Name:LIDYA
Middle Name:MARGARITA
Last Name:LATABAN-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 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:20 CYPRESS POINT PKWY STE A
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7528
Practice Address - Country:US
Practice Address - Phone:386-586-7005
Practice Address - Fax:844-867-3940
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15204208D00000X
FLACN911208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN911OtherFLORIDA LICENSE
PRB159OtherFIRST MEDICAL
PR22385OtherTRIPLE S DE PUERTO RICO
PR9700031OtherHUMANA
PRB159OtherFIRST MEDICAL
FLACN911OtherFLORIDA LICENSE