Healthcare Provider Details

I. General information

NPI: 1417902685
Provider Name (Legal Business Name): CARLOS D AMY VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 STATE ROAD 20
INTERLACHEN FL
32148-2737
US

IV. Provider business mailing address

1302 RIVER ST
PALATKA FL
32177-5042
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-4914
  • Fax: 386-684-6524
Mailing address:
  • Phone: 386-328-0108
  • Fax: 386-325-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15813
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: