Provider Demographics
NPI:1992990212
Name:VAZQUEZ, JORGE L (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 S SEMORAN BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1459
Mailing Address - Country:US
Mailing Address - Phone:407-384-9165
Mailing Address - Fax:407-384-9174
Practice Address - Street 1:1140 S SEMORAN BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1459
Practice Address - Country:US
Practice Address - Phone:407-384-9165
Practice Address - Fax:407-384-9174
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107365208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003738500Medicaid
FV2369898OtherDEA
FV2369898OtherDEA