Provider Demographics
NPI:1396187795
Name:LOPEZ, CARLOS OSMUNDO
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:OSMUNDO
Last Name:LOPEZ
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 1:2150 BAY DR APT 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-3479
Mailing Address - Country:US
Mailing Address - Phone:305-491-7715
Mailing Address - Fax:
Practice Address - Street 1:2150 BAY DR APT 2
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-3479
Practice Address - Country:US
Practice Address - Phone:305-491-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31783225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist