Provider Demographics
NPI:1316913171
Name:LOPEZ, IVELISSE (MD)
Entity type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:
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 1:2880 S OSCEOLA AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-5431
Mailing Address - Country:US
Mailing Address - Phone:407-843-0443
Mailing Address - Fax:407-843-0442
Practice Address - Street 1:2880 S OSCEOLA AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-5431
Practice Address - Country:US
Practice Address - Phone:407-843-0443
Practice Address - Fax:407-843-0442
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82595207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262579200Medicaid
FLBL7349120OtherDEA
FLH43063Medicare UPIN
FL03007XMedicare PIN
FL03007ZMedicare ID - Type Unspecified