Provider Demographics
NPI:1023097136
Name:VASTA, JEFFREY SCOTT (MD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:VASTA
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 1:3633 LITTLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1815
Mailing Address - Country:US
Mailing Address - Phone:727-375-2222
Mailing Address - Fax:866-244-2335
Practice Address - Street 1:3633 LITTLE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1818
Practice Address - Country:US
Practice Address - Phone:727-375-2222
Practice Address - Fax:866-244-2335
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72377207R00000X
FLME0072377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
K4295Medicare ID - Type Unspecified
G84857Medicare UPIN