Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081P2900X | Pain Medicine | 15704 | PR |
N | 2081P2900X | Pain Medicine | 4301087534 | MI |
Y | 2081P2900X | Pain Medicine | ME 107153 | FL |
NPI | 1144458100 |
---|---|
Provider Name | Dr. Manuel Enrique Lopez Diez |
First Address | Ponte Vedra, FL 32081-0846 |
Second Address | Palm Coast, FL 32137-3666 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2009 |
Last Update Date | 28/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
008263500 | (05) | FL |