Healthcare Provider Details

I. General information

NPI: 1730830217
Provider Name (Legal Business Name): ANY ESTER QUEZADA DOMAZET MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 W GRANADA BLVD STE 102
ORMOND BEACH FL
32174-5109
US

IV. Provider business mailing address

601 S HARBOUR ISLAND BLVD STE 200
TAMPA FL
33602-5925
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-4615
  • Fax: 386-672-4624
Mailing address:
  • Phone: 727-322-3439
  • Fax: 800-928-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number025158
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: