Provider Demographics
NPI:1043253479
Name:LOPEZ, CAMILO E (PA)
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:E
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10445 SW 128TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-5540
Mailing Address - Country:US
Mailing Address - Phone:305-232-8234
Mailing Address - Fax:305-259-1931
Practice Address - Street 1:10445 SW 128TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-5540
Practice Address - Country:US
Practice Address - Phone:786-290-3211
Practice Address - Fax:305-259-1931
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9100817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK-3707Medicare ID - Type Unspecified