Healthcare Provider Details

I. General information

NPI: 1619437357
Provider Name (Legal Business Name): CONNAN VACA MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

333 FERN ST APT 1404
WEST PALM BEACH FL
33401-5971
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-6973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME162405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: