Provider Demographics
NPI:1578858577
Name:ESCOBAR, VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ESCOBAR
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 1:18923 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5268
Mailing Address - Country:US
Mailing Address - Phone:813-803-7150
Mailing Address - Fax:813-803-7167
Practice Address - Street 1:18923 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5268
Practice Address - Country:US
Practice Address - Phone:813-803-7150
Practice Address - Fax:813-803-7167
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME125246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLII697ZOtherPTAN
FL015680400Medicaid