Healthcare Provider Details

I. General information

NPI: 1144289133
Provider Name (Legal Business Name): JULIO B LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S W C OWENS AVE
CLEWISTON FL
33440-3637
US

IV. Provider business mailing address

4450 S TIFFANY DR
WEST PALM BEACH FL
33407-3241
US

V. Phone/Fax

Practice location:
  • Phone: 863-983-7813
  • Fax: 863-983-9604
Mailing address:
  • Phone: 561-844-9443
  • Fax: 561-844-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: