Provider Demographics
NPI:1760674501
Name:CAMILO E. LOPEZ PA
Entity Type:Organization
Organization Name:CAMILO E. LOPEZ PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILO
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:786-290-3211
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:786-290-3211
Mailing Address - Fax:
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:305-232-8234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291032200Medicaid
FLK3707Medicare PIN