Provider Demographics
NPI:1609853225
Name:ACEVEDO VAZQUEZ, JORGE L
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:ACEVEDO 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 1:7630 SOUTHERN BROOK BND
Mailing Address - Street 2:APT 205
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-1824
Mailing Address - Country:US
Mailing Address - Phone:787-667-0988
Mailing Address - Fax:787-667-0988
Practice Address - Street 1:4160 N ARMENIA AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6453
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:866-285-7068
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN651208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE82749Medicare UPIN
82151Medicare ID - Type Unspecified