Provider Demographics
NPI:1811483233
Name:LOPEZ LARA, ALBERTO TOMAS
Entity type:Individual
Prefix:
First Name:ALBERTO
Middle Name:TOMAS
Last Name:LOPEZ LARA
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 1:9500 S DADELAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2866
Mailing Address - Country:US
Mailing Address - Phone:305-468-4185
Mailing Address - Fax:305-675-3378
Practice Address - Street 1:4791 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3938
Practice Address - Country:US
Practice Address - Phone:305-825-0500
Practice Address - Fax:305-825-5557
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9365056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily