Healthcare Provider Details

I. General information

NPI: 1346819711
Provider Name (Legal Business Name): JOSE LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15924 SW 92ND AVE
MIAMI FL
33157-1842
US

IV. Provider business mailing address

10918 SW 181ST TER
PALMETTO BAY FL
33157-9002
US

V. Phone/Fax

Practice location:
  • Phone: 305-964-5824
  • Fax: 786-452-1200
Mailing address:
  • Phone: 305-753-2179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: