Healthcare Provider Details

I. General information

NPI: 1962509521
Provider Name (Legal Business Name): WASHINGTON DARIO BAQUERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 COLONIAL BLVD STE C1
FORT MYERS FL
33907-1197
US

IV. Provider business mailing address

1705 COLONIAL BLVD STE C1
FORT MYERS FL
33907-1197
US

V. Phone/Fax

Practice location:
  • Phone: 239-275-4141
  • Fax: 239-275-4879
Mailing address:
  • Phone: 239-275-4141
  • Fax: 239-275-4879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0034296F
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME34296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: