Healthcare Provider Details

I. General information

NPI: 1104824077
Provider Name (Legal Business Name): RENE LUIS LOPEZ-GUERRERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-643-0133
  • Fax: 305-643-1728
Mailing address:
  • Phone: 305-643-0133
  • Fax: 305-643-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME0049266
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0049266
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: