Basic Information
| Provider Information | |||||||||
| NPI: | 1154393221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ-PERTEJO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3461 FAIRLANE FARMS RD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Practice Location | |||||||||
| Address1: | 3461 FAIRLANE FARMS RD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME0079884 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 35281 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 258840400 | 05 | FL | MEDICAID |