Healthcare Provider Details

I. General information

NPI: 1952623597
Provider Name (Legal Business Name): ANTONIO JOSE LOPEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 08/21/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 85TH ST
MIAMI BEACH FL
33141-1109
US

IV. Provider business mailing address

719 85TH ST
MIAMI BEACH FL
33141-1109
US

V. Phone/Fax

Practice location:
  • Phone: 786-523-3208
  • Fax:
Mailing address:
  • Phone: 786-523-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTPPA562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: