Provider Demographics
NPI:1487757001
Name:LOPEZ, GLORIA (MD)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 PONCE DE LEON BLVD
Mailing Address - Street 2:#607
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:305-443-2324
Mailing Address - Fax:305-443-6301
Practice Address - Street 1:747 PONCE DE LEON BLVD
Practice Address - Street 2:#607
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:305-443-2324
Practice Address - Fax:305-443-6301
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL38886208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376045600Medicaid
96319Medicare ID - Type Unspecified
FL376045600Medicaid