=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215264536
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REYNALDO LOPEZ M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2009
-----------------------------------------------------
Last Update Date | 07/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4855 NW 183RD ST
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33055-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-501-3757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19161 SENECA AVE
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33332-2436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-501-3757
-----------------------------------------------------
Fax | 954-400-3353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 18208
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME111725
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------