Provider Demographics
NPI:1760424808
Name:LOPEZ, HERMINSUL J (PT)
Entity Type:Individual
Prefix:
First Name:HERMINSUL
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:HERMINSUL
Other - Middle Name:
Other - Last Name:JARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:8390 W FLAGLER ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-2039
Mailing Address - Country:US
Mailing Address - Phone:305-221-1685
Mailing Address - Fax:305-221-1686
Practice Address - Street 1:8390 W FLAGLER ST
Practice Address - Street 2:# 203
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2039
Practice Address - Country:US
Practice Address - Phone:305-221-1685
Practice Address - Fax:305-221-1686
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 14185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888358100Medicaid
FLY8351OtherPHYSICAL THERAPIST
FLAD505Medicare PIN