Provider Demographics
NPI:1578613022
Name:VAZQUEZ-DIAZ, ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:VAZQUEZ-DIAZ
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 1:100 W GORE ST STE 600
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1051
Mailing Address - Country:US
Mailing Address - Phone:321-842-6671
Mailing Address - Fax:321-843-6447
Practice Address - Street 1:100 W GORE ST STE 600
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1051
Practice Address - Country:US
Practice Address - Phone:321-842-6671
Practice Address - Fax:321-843-6447
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR136552080A0000X
FLME 1149352084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 114935OtherFLORIDA MEDICAL BOARD
FL008698000Medicaid