Provider Demographics
NPI:1013388586
Name:GARZONLOPEZ, CAMILO EDGARDO
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:EDGARDO
Last Name:GARZONLOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 NW 107TH AVE APT 1310
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4940
Mailing Address - Country:US
Mailing Address - Phone:305-301-7085
Mailing Address - Fax:
Practice Address - Street 1:800 NW 95TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2032
Practice Address - Country:US
Practice Address - Phone:305-853-5848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25555225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant