Provider Demographics
NPI:1255895348
Name:LOPEZ, JOSE LUIS
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:504 SW BUCCHI GLN
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-2936
Mailing Address - Country:US
Mailing Address - Phone:352-474-9788
Mailing Address - Fax:
Practice Address - Street 1:6459 SW COUNTY ROAD 18 UNIT 4
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-3464
Practice Address - Country:US
Practice Address - Phone:352-474-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL474115030Medicaid