MEDICARE: LARGO PRIMARY CARE LLC

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	207R00000X	Internal Medicine Physician	0062810	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	:	1558540534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARGO PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	1258 W BAY DR
Second Line	:	SUITE A
City	:	LARGO
State	:	FL
Zip	:	33770-2242
Country	:	US
Telephone Number	:	727-585-5431
Fax Number	:	727-585-1543

Provider Business Practice Location Address
First Line	:	1258 W BAY DR
Second Line	:	SUITE A
City	:	LARGO
State	:	FL
Zip	:	33770-2242
Country	:	US
Telephone Number	:	727-585-5431
Fax Number	:	727-585-1543

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. CHRISTINA ANN VAZQUEZ
Credential	:
Telephone Number	:	727-585-5431

Provider Enumeration Date	:	10/26/2007
Last Update Date	:	03/13/2009

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