Provider Demographics
NPI:1164279527
Name:LOPEZ FRONTELA, JUAN CARLOS (SA-C)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:LOPEZ FRONTELA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLOS
Other - Last Name:LOPEZ FRONTELA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SA-C
Mailing Address - Street 1:615 E MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1835
Mailing Address - Country:US
Mailing Address - Phone:407-675-1489
Mailing Address - Fax:
Practice Address - Street 1:615 E MARTIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1835
Practice Address - Country:US
Practice Address - Phone:407-675-1489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24-225246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist