Healthcare Provider Details

I. General information

NPI: 1124319611
Provider Name (Legal Business Name): DIBANNI VASQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SW 3RD ST APT 4308
MIAMI FL
33130-2995
US

IV. Provider business mailing address

90 SW 3RD ST APT 4308
MIAMI FL
33130-2995
US

V. Phone/Fax

Practice location:
  • Phone: 305-972-1073
  • Fax:
Mailing address:
  • Phone: 305-972-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 109534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: