Healthcare Provider Details

I. General information

NPI: 1457309601
Provider Name (Legal Business Name): VINCENT S. MUNIZZA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13650 METROPOLIS AVE SUITE 101
FORT MYERS FL
33912
US

IV. Provider business mailing address

12550 PROFESSIONAL PARK DR. SUITE 11
FORT MYERS FL
33913
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-2111
  • Fax: 239-482-4404
Mailing address:
  • Phone: 239-768-2111
  • Fax: 239-482-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA2064
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2064
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2064
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: