Provider Demographics
NPI:1760470306
Name:LOPEZ, IVAN D (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:D
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:D
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:439 SW MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0440
Mailing Address - Country:US
Mailing Address - Phone:386-487-0800
Mailing Address - Fax:
Practice Address - Street 1:4300 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-4006
Practice Address - Country:US
Practice Address - Phone:352-374-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV242272084P0804X, 2084N0400X
FLME1082282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H29425Medicare UPIN
H29425Medicare UPIN