Provider Demographics
NPI:1356675995
Name:LOPEZ, MAXIMO (LMT)
Entity Type:Individual
Prefix:
First Name:MAXIMO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SW 2ND AVE UNIT 1702
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3599
Mailing Address - Country:US
Mailing Address - Phone:786-866-9727
Mailing Address - Fax:
Practice Address - Street 1:850 SW 2ND AVE UNIT 1702
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3599
Practice Address - Country:US
Practice Address - Phone:786-866-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL40187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004438800Medicaid