MEDICARE: JORGE MANUEL GOMEZ VIZCARRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	21111	PR
2	208D00000X	General Practice Physician	ACN1356	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366911471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE MANUEL GOMEZ VIZCARRA MD

Provider Business Mailing Address
First Line	:	5400 PINEHURST DR
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34606-3833
Country	:	US
Telephone Number	:	352-277-5348
Fax Number	:	352-606-2857

Provider Business Practice Location Address
First Line	:	1100 SW SAINT LUCIE WEST BLVD STE 209
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-1735
Country	:	US
Telephone Number	:	772-204-8889
Fax Number	:	772-204-8895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	03/28/2025

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