Provider Demographics
NPI:1184813149
Name:LOPEZ-CANINO, JORGE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:LOPEZ-CANINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 653153
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33265-3153
Mailing Address - Country:US
Mailing Address - Phone:305-330-6692
Mailing Address - Fax:305-330-6686
Practice Address - Street 1:15495 EAGLE NEST LN STE 245
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014
Practice Address - Country:US
Practice Address - Phone:305-330-6692
Practice Address - Fax:305-330-6686
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123509208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015 521 800Medicaid
FLIL455ZMedicare PIN