Healthcare Provider Details

I. General information

NPI: 1811483233
Provider Name (Legal Business Name): ALBERTO TOMAS LOPEZ LARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4791 W 4TH AVE
HIALEAH FL
33012-3938
US

IV. Provider business mailing address

9500 S DADELAND BLVD STE 200
MIAMI FL
33156-2866
US

V. Phone/Fax

Practice location:
  • Phone: 305-825-0500
  • Fax: 305-825-5557
Mailing address:
  • Phone: 305-468-4185
  • Fax: 305-675-3378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9365056
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: