Healthcare Provider Details

I. General information

NPI: 1801865654
Provider Name (Legal Business Name): BRIAN VAZQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 NORTH CLYDE MORRIS BLVD. HALIFAX HEALTH MEDICAL CENTER
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

303 NORTH CLYDE MORRIS BLVD. HALIFAX HEALTH MEDICAL CENTER
DAYTONA BEACH FL
32114-2709
US

V. Phone/Fax

Practice location:
  • Phone: 386-254-2285
  • Fax: 386-425-1304
Mailing address:
  • Phone: 386-254-2285
  • Fax: 386-425-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0085832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: