Provider Demographics
NPI:1619016185
Name:LISETTE VAZQUEZ DO PA
Entity Type:Organization
Organization Name:LISETTE VAZQUEZ DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PA
Authorized Official - Phone:786-243-4100
Mailing Address - Street 1:5663 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1019
Mailing Address - Country:US
Mailing Address - Phone:786-243-4100
Mailing Address - Fax:786-243-4111
Practice Address - Street 1:909 N KROME AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4408
Practice Address - Country:US
Practice Address - Phone:786-243-4100
Practice Address - Fax:786-243-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9315261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7617825OtherAETNA
FL48582OtherBCBS
FL170465OtherHUMANA
FL304927OtherAVMED
FL57338OtherNHP
FL7617825OtherAETNA
FL304927OtherAVMED