Healthcare Provider Details

I. General information

NPI: 1578858577
Provider Name (Legal Business Name): VANESSA ESCOBAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18923 STATE ROAD 54
LUTZ FL
33558-5268
US

IV. Provider business mailing address

18923 STATE ROAD 54
LUTZ FL
33558-5268
US

V. Phone/Fax

Practice location:
  • Phone: 813-803-7150
  • Fax: 813-803-7167
Mailing address:
  • Phone: 813-803-7150
  • Fax: 813-803-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME125246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: