Provider Demographics
NPI:1669515730
Name:LOPEZ, JOSE CARLOS (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:CARLOS
Last Name:LOPEZ
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 1:13168 SW 188TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3002
Mailing Address - Country:US
Mailing Address - Phone:305-609-7649
Mailing Address - Fax:305-248-6558
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4934
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:305-248-6558
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55324174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015064400Medicaid
ME55324OtherFLORIDA HEALTH DEPARTMENT