Provider Demographics
NPI:1063668002
Name:LOPEZ, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
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 1:3105 W WATERS AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 W WATERS AVE STE 304
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2872
Practice Address - Country:US
Practice Address - Phone:813-933-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53981225700000X
FLBMO728502471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist