Healthcare Provider Details

I. General information

NPI: 1235574484
Provider Name (Legal Business Name): AGUSTIN RODOLFO LOPEZ LEIROS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 DEL PRADO BLVD S STE 300
CAPE CORAL FL
33990-6740
US

IV. Provider business mailing address

4102 NW 39TH ST
CAPE CORAL FL
33993-7853
US

V. Phone/Fax

Practice location:
  • Phone: 786-577-2018
  • Fax: 786-957-5158
Mailing address:
  • Phone: 786-577-2018
  • Fax: 786-957-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS47176
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9574671
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11023966
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: