Healthcare Provider Details

I. General information

NPI: 1235380643
Provider Name (Legal Business Name): NUTAN JYOTHI VAZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. NUTAN JYOTHI VAZ

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 300
COON RAPIDS MN
55433-2772
US

IV. Provider business mailing address

245 W AIRPORT BLVD
PENSACOLA FL
32505-2254
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-0808
  • Fax: 763-236-6065
Mailing address:
  • Phone: 850-473-3726
  • Fax: 850-505-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD-24844
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number162504
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number78892
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME113167
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberPT21148
License Number StateND
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number001165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: