Provider Demographics
NPI:1174713184
Name:LOPEZRIVERA, LUIS ANGEL (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANGEL
Last Name:LOPEZRIVERA
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 1:3116 BORDER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-9060
Mailing Address - Country:US
Mailing Address - Phone:850-333-7575
Mailing Address - Fax:
Practice Address - Street 1:3189 COLONEL GREG MALLOY RD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-6705
Practice Address - Country:US
Practice Address - Phone:850-683-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17506208D00000X
FLACN390208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007626400Medicaid
FL007626400Medicaid