Provider Demographics
NPI:1528066941
Name:LOYOLA, RENE MARIO (MD)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:MARIO
Last Name:LOYOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SE GOLDTREE DR
Mailing Address - Street 2:SUITE 102-104
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7582
Mailing Address - Country:US
Mailing Address - Phone:772-335-8446
Mailing Address - Fax:772-335-8499
Practice Address - Street 1:1400 SE GOLDTREE DR
Practice Address - Street 2:SUITE 102-104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-335-8446
Practice Address - Fax:772-335-8499
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0033328207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068483000Medicaid
FLD62648Medicare UPIN
FL95895XMedicare PIN