Basic Information
| Provider Information | |||||||||
| NPI: | 1669515730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | CARLOS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13168 SW 188TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331773002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056097649 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Practice Location | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME55324 | FL | N | Other Service Providers | Specialist | 2084P0800X | ME55324 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 015064400 | 05 | FL | MEDICAID | ME55324 | 01 | FLORIDA HEALTH DEPARTMENT | OTHER |