MEDICARE: MR. JUAN J LOPEZ

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	156FX1800X	Optician	DO4898	FL

General Provider Information

NPI Number	:	1821231671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN J LOPEZ

Provider Business Mailing Address
First Line	:	5207 W 24TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-4007
Country	:	US
Telephone Number	:	305-231-2035
Fax Number	:	305-231-2105

Provider Business Practice Location Address
First Line	:	5207 W 24TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33016-4007
Country	:	US
Telephone Number	:	305-231-2035
Fax Number	:	305-231-2105

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

Provider Enumeration Date	:	04/09/2009
Last Update Date	:	04/09/2009

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