Basic Information
| Provider Information | |||||||||
| NPI: | 1841620390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VAZQUEZ | ||||||||
| OtherFirstName: | GLORIA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4780 SW 64TH AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333144400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544341705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1437 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | DANIA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330044348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543999941 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN 796 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.