Basic Information
| Provider Information | |||||||||
| NPI: | 1841267143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ-MENDEZ | ||||||||
| FirstName: | ADA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632940670 | ||||||||
| FaxNumber: | 8632983200 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632940670 | ||||||||
| FaxNumber: | 8632983200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2006 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME58686 | FL | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207RR0500X | ME58686 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 11595 | 01 | FL | BCBS FL | OTHER | 371637600 | 05 | FL | MEDICAID | P00715125 | 01 | FL | RRM PTAN | OTHER |