Basic Information
| Provider Information | |||||||||
| NPI: | 1669572533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | CARLOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054417179 | ||||||||
| FaxNumber: | 3054487134 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054417179 | ||||||||
| FaxNumber: | 3054487134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | ME 93502 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 273059600 | 05 | FL | MEDICAID |