Provider Demographics
NPI:1992753016
Name:LOPEZ, JOSEPH JULIAN (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JULIAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2103
Mailing Address - Country:US
Mailing Address - Phone:904-259-3151
Mailing Address - Fax:
Practice Address - Street 1:159 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2103
Practice Address - Country:US
Practice Address - Phone:904-259-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6073207RG0100X
MI4301097716207RG0100X
IN01068725A207RG0100X
IL036.126463207RG0100X
FLME 123793207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015372200Medicaid
NV002019037Medicaid
NV100010704OtherRR MEDICARE
NVNV0397OtherBCBS ID
FLKK9HWOtherBCBS
FLP01552787OtherRR MEDICARE
NVD87512Medicare UPIN
FL015372200Medicaid
NV002019037Medicaid
FLP01552787OtherRR MEDICARE