Healthcare Provider Details

I. General information

NPI: 1285789594
Provider Name (Legal Business Name): MARY ANN VACCARELLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 45TH ST STE 206
MANGONIA PARK FL
33407-2450
US

IV. Provider business mailing address

5955 PONCE DE LEON BLVD
CORAL GABLES FL
33146-2423
US

V. Phone/Fax

Practice location:
  • Phone: 561-844-8354
  • Fax:
Mailing address:
  • Phone: 305-611-1515
  • Fax: 305-662-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberME 0056044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: