Basic Information
Provider Information | |||||||||
NPI: | 1417135997 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NELSON LOPEZ MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NELSON LOPEZ MD | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2609 W WOOLBRIGHT RD | ||||||||
Address2: | SUITE 5 | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334366634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617344535 | ||||||||
FaxNumber: | 5617347530 | ||||||||
Practice Location | |||||||||
Address1: | 2609 W WOOLBRIGHT RD | ||||||||
Address2: | SUITE 5 | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334366634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617344535 | ||||||||
FaxNumber: | 5617347530 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2008 | ||||||||
LastUpdateDate: | 04/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOPEZ | ||||||||
AuthorizedOfficialFirstName: | NELSON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 5617344535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | ME0027191 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | K1646 | 01 | FL | MEDICARE PROVIDER | OTHER |