Healthcare Provider Details

I. General information

NPI: 1164369179
Provider Name (Legal Business Name): WILLY EBERTO COWLEY LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 W 49TH PL
HIALEAH FL
33012-3113
US

IV. Provider business mailing address

6716 SW 128TH PL
MIAMI FL
33183-1332
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-2500
  • Fax:
Mailing address:
  • Phone: 347-863-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: