Provider Demographics
NPI:1144780651
Name:VASQUEZ, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2231
Mailing Address - Country:US
Mailing Address - Phone:727-871-1344
Mailing Address - Fax:
Practice Address - Street 1:304 1ST AVE S
Practice Address - Street 2:
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-2231
Practice Address - Country:US
Practice Address - Phone:727-871-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRZUA0012347622515OtherTRIPLE-S SALUD