Provider Demographics
NPI:1417902685
Name:AMY VAZQUEZ, CARLOS D (MD)
Entity Type:Individual
Prefix:MR
First Name:CARLOS D
Middle Name:
Last Name:AMY VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-0108
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1213 STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-2737
Practice Address - Country:US
Practice Address - Phone:386-684-4914
Practice Address - Fax:386-684-6524
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15813208D00000X
FLACN1030208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR15813OtherMEDICAL LICENSE
FLACN1030OtherFLORIDA MEDICAL LICENSE