Provider Demographics
NPI:1013412394
Name:VAZQUEZ, STEPHANIE NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 JOE DIMAGGIO DR
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5487
Mailing Address - Country:US
Mailing Address - Phone:954-265-4461
Mailing Address - Fax:
Practice Address - Street 1:1005 JOE DIMAGGIO DR
Practice Address - Street 2:ATTN: PEDIATRIC RESIDENCY PROGRAM
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5487
Practice Address - Country:US
Practice Address - Phone:954-265-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME151600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111-661-800Medicaid