Healthcare Provider Details

I. General information

NPI: 1720646136
Provider Name (Legal Business Name): GABRIEL VAZQUEZ-LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

6812 CASTILLO CT
ORLANDO FL
32822-3920
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6611
  • Fax:
Mailing address:
  • Phone: 787-361-6776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number9483758
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11005724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: