Provider Demographics
NPI:1568450617
Name:LOPEZ DOMINGUEZ, MARIA VICTORIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:VICTORIA
Last Name:LOPEZ DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:VICTORIA
Other - Last Name:LOPEZ DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14100 58TH ST N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-9900
Mailing Address - Country:US
Mailing Address - Phone:727-824-8181
Mailing Address - Fax:
Practice Address - Street 1:14100 58TH ST N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-9900
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81536208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010564800Medicaid