Provider Demographics
NPI:1619374295
Name:LOPEZ NOVOA, CARLOS ERNESTO (PT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ERNESTO
Last Name:LOPEZ NOVOA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 MARY ST
Mailing Address - Street 2:
Mailing Address - City:COCONUT GROVE
Mailing Address - State:FL
Mailing Address - Zip Code:33133-5232
Mailing Address - Country:US
Mailing Address - Phone:305-448-8100
Mailing Address - Fax:305-448-8100
Practice Address - Street 1:3250 MARY ST
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-5232
Practice Address - Country:US
Practice Address - Phone:305-448-8100
Practice Address - Fax:305-448-8100
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014108100Medicaid
FL014108100Medicaid