Healthcare Provider Details

I. General information

NPI: 1366911471
Provider Name (Legal Business Name): JORGE MANUEL GOMEZ VIZCARRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SW SAINT LUCIE WEST BLVD STE 209
PORT ST LUCIE FL
34986-1735
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 772-204-8889
  • Fax: 772-204-8895
Mailing address:
  • Phone: 352-277-5348
  • Fax: 352-606-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21111
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: