Provider Demographics
NPI:1821231671
Name:LOPEZ, JUAN J
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:J
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 1:5207 W 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4007
Mailing Address - Country:US
Mailing Address - Phone:305-231-2035
Mailing Address - Fax:305-231-2105
Practice Address - Street 1:5207 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-4007
Practice Address - Country:US
Practice Address - Phone:305-231-2035
Practice Address - Fax:305-231-2105
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO4898156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26-2464364OtherEMPLOYER IDENTIFICATION NUMBER