Provider Demographics
NPI:1285789594
Name:VACCARELLO, MARY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:VACCARELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5955 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2423
Mailing Address - Country:US
Mailing Address - Phone:305-611-1515
Mailing Address - Fax:305-662-3723
Practice Address - Street 1:927 45TH ST STE 206
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2450
Practice Address - Country:US
Practice Address - Phone:561-844-8354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 00560442080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379171800Medicaid
FLME 0056044OtherMEDICAL LICENSE NUMBER