MEDICARE: MR. ROBERTO CARLOS AZOCAR PEROZO SR. SA

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	246ZC0007X	Surgical Assistant	22-603	WI

General Provider Information

NPI Number	:	1639969041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERTO CARLOS AZOCAR PEROZO SR. SA

Provider Business Mailing Address
First Line	:	9751 MOUNTAIN LAKE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-5999
Country	:	US
Telephone Number	:	786-395-4391
Fax Number	:

Provider Business Practice Location Address
First Line	:	9751 MOUNTAIN LAKE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-5999
Country	:	US
Telephone Number	:	786-395-4391
Fax Number	:

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

Provider Enumeration Date	:	05/08/2025
Last Update Date	:	05/08/2025

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