Healthcare Provider Details

I. General information

NPI: 1083070627
Provider Name (Legal Business Name): LUIS ANGEL VARGAS-MASSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 S NARCOOSSEE RD
SAINT CLOUD FL
34771-7211
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 407-986-9642
  • Fax: 407-593-6102
Mailing address:
  • Phone: 321-332-6947
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number19948
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: