Basic Information
| Provider Information | |||||||||
| NPI: | 1285789594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VACCARELLO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056111515 | ||||||||
| FaxNumber: | 3056623723 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 45TH ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | MANGONIA PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618448354 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | ME 0056044 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 379171800 | 05 | FL | MEDICAID | ME 0056044 | 01 | FL | MEDICAL LICENSE NUMBER | OTHER |