Provider Demographics
NPI:1972644342
Name:LOPEZ PRIETO, MANUEL (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:LOPEZ PRIETO
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 1:26301 SW 133RD CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6892
Mailing Address - Country:US
Mailing Address - Phone:305-793-0959
Mailing Address - Fax:
Practice Address - Street 1:11474 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-6575
Practice Address - Country:US
Practice Address - Phone:305-793-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79042208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45913OtherBCBS PROV NUMBER
FL257771200Medicaid
FLME79042OtherSTATE LICENSE NUMBER
FLE3597DMedicare PIN
FLME79042OtherSTATE LICENSE NUMBER