Healthcare Provider Details

I. General information

NPI: 1164710182
Provider Name (Legal Business Name): JOSE LUIS LOPEZ RIVERA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N WESTMONTE DR # 1001
ALTAMONTE SPRINGS FL
32714-3311
US

IV. Provider business mailing address

210 N WESTMONTE DR # 1001
ALTAMONTE SPRINGS FL
32714-3311
US

V. Phone/Fax

Practice location:
  • Phone: 407-633-0401
  • Fax: 407-214-2749
Mailing address:
  • Phone: 407-633-0401
  • Fax: 407-214-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8746A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCDR0000225
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME138937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: