Provider Demographics
NPI:1598912032
Name:CENTENO VAZQUEZ, NICOLAS E
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:E
Last Name:CENTENO VAZQUEZ
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 1:1330 LAKE FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2120
Mailing Address - Country:US
Mailing Address - Phone:787-370-9628
Mailing Address - Fax:352-241-6361
Practice Address - Street 1:1330 LAKE FRANCIS DR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2120
Practice Address - Country:US
Practice Address - Phone:787-370-9628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR879174400000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR879OtherPUERTO RICO MEDICAL LICENSE