MEDICARE: AGUSTIN RODOLFO LOPEZ LEIROS RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS47176	FL
2	163W00000X	Registered Nurse	RN9574671	FL
3	363LF0000X	Family Nurse Practitioner	APRN11023966	FL

General Provider Information

NPI Number	:	1235574484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTIN RODOLFO LOPEZ LEIROS RPH

Provider Business Mailing Address
First Line	:	4102 NW 39TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-7853
Country	:	US
Telephone Number	:	786-577-2018
Fax Number	:	786-957-5158

Provider Business Practice Location Address
First Line	:	1631 DEL PRADO BLVD S STE 300
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-6740
Country	:	US
Telephone Number	:	786-577-2018
Fax Number	:	786-957-5158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	06/19/2026

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