Provider Demographics
NPI:1316308752
Name:LOPEZ, EDGAR (PTA)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16884 SW 144TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-2012
Mailing Address - Country:US
Mailing Address - Phone:305-607-4149
Mailing Address - Fax:
Practice Address - Street 1:311 NE 8TH ST STE 104
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4734
Practice Address - Country:US
Practice Address - Phone:305-248-8600
Practice Address - Fax:844-272-8151
Is Sole Proprietor?:No
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 24429225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant