Healthcare Provider Details

I. General information

NPI: 1689847568
Provider Name (Legal Business Name): JUAN CARLOS GALVEZ VARGAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 09/12/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 WASHINGTON ST STE 202
HOLLYWOOD FL
33021-8283
US

IV. Provider business mailing address

3702 WASHINGTON ST STE 202
HOLLYWOOD FL
33021-8283
US

V. Phone/Fax

Practice location:
  • Phone: 954-964-6114
  • Fax: 954-962-1994
Mailing address:
  • Phone: 954-964-6114
  • Fax: 954-962-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036128480
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA119932
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53001
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME126491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: