Provider Demographics
NPI:1164404257
Name:AZZARA, VINCENT A (DO)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:A
Last Name:AZZARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14429 REFLECTION LAKES DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1813
Mailing Address - Country:US
Mailing Address - Phone:239-770-5465
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:14429 REFLECTION LAKES DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1813
Practice Address - Country:US
Practice Address - Phone:239-770-5465
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15629OtherSTAYWELL
FL055936900Medicaid
FL000013683GOtherHUMANA
FL80533OtherBC/BS OF FLORIDA
FL104456OtherAVMED
FL80533ZMedicare PIN
FL104456OtherAVMED