Provider Demographics
NPI:1194552018
Name:ROMERO-LOPEZ, MARIO ANDRE
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ANDRE
Last Name:ROMERO-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 1:1414 BRIAR OAK DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6142
Mailing Address - Country:US
Mailing Address - Phone:407-818-3203
Mailing Address - Fax:
Practice Address - Street 1:1414 BRIAR OAK DR
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-6142
Practice Address - Country:US
Practice Address - Phone:407-818-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program