Provider Demographics
NPI:1457098253
Name:LOPEZ, WILCANOR (MD)
Entity type:Individual
Prefix:DR
First Name:WILCANOR
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 W OAK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4973
Mailing Address - Country:US
Mailing Address - Phone:407-931-0444
Mailing Address - Fax:407-962-4446
Practice Address - Street 1:2330 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8989
Practice Address - Country:US
Practice Address - Phone:407-931-0444
Practice Address - Fax:407-962-4446
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRACN1663208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice