Provider Demographics
NPI:1740546142
Name:VAZQUEZ, VIVIANA SMITH (MD)
Entity type:Individual
Prefix:
First Name:VIVIANA
Middle Name:SMITH
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIVIANA
Other - Middle Name:
Other - Last Name:SMITH TORRES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:904-642-6100
Mailing Address - Fax:904-642-5154
Practice Address - Street 1:155 BARTRAM MARKET DR STE 120
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4582
Practice Address - Country:US
Practice Address - Phone:904-650-2193
Practice Address - Fax:904-201-6350
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454462208000000X
FLME139341208000000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102072000Medicaid