Healthcare Provider Details

I. General information

NPI: 1104292846
Provider Name (Legal Business Name): JUAN PINEDA LOPEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5564 E GRANT STREET
ORLANDO FL
32822-5301
US

IV. Provider business mailing address

5564 E. GRANT STREET
ORLANDO FL
32822-5301
US

V. Phone/Fax

Practice location:
  • Phone: 321-235-6230
  • Fax: 321-235-6246
Mailing address:
  • Phone: 321-235-6230
  • Fax: 321-235-6246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN683
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18959
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: