Healthcare Provider Details

I. General information

NPI: 1528066941
Provider Name (Legal Business Name): RENE MARIO LOYOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SE GOLDTREE DR SUITE 102-104
PORT ST LUCIE FL
34952-7582
US

IV. Provider business mailing address

1400 SE GOLDTREE DR SUITE 102-104
PORT ST LUCIE FL
34952-7582
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-8446
  • Fax: 772-335-8499
Mailing address:
  • Phone: 772-335-8446
  • Fax: 772-335-8499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0033328
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: