Healthcare Provider Details

I. General information

NPI: 1013426857
Provider Name (Legal Business Name): EDDY JOSE LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4507 N ARMENIA AVE
TAMPA FL
33603-2703
US

IV. Provider business mailing address

11804 ROSSMAYNE DR
RIVERVIEW FL
33569-5657
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-4100
  • Fax: 813-876-4153
Mailing address:
  • Phone: 813-390-1935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: