Basic Information
| Provider Information | |||||||||
| NPI: | 1144458100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ DIEZ | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | ENRIQUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 BENT TRL | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320810846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047075498 | ||||||||
| FaxNumber: | 9042121351 | ||||||||
| Practice Location | |||||||||
| Address1: | 4863 PALM COAST PKWY NW | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321373666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862227746 | ||||||||
| FaxNumber: | 9042121351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 15704 | PR | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | 4301087534 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | ME 107153 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008263500 | 05 | FL | MEDICAID |