Provider Demographics
NPI:1174560619
Name:ID PROFESSIONALS OF SOUTH FLORIDA LLC
Entity type:Organization
Organization Name:ID PROFESSIONALS OF SOUTH FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-495-5102
Mailing Address - Street 1:PO BOX 371082
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-1082
Mailing Address - Country:US
Mailing Address - Phone:305-698-5997
Mailing Address - Fax:305-698-5998
Practice Address - Street 1:1790 W 49TH ST
Practice Address - Street 2:SUITE 400-9
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2992
Practice Address - Country:US
Practice Address - Phone:305-698-5997
Practice Address - Fax:305-698-5998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75291207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty