Healthcare Provider Details

I. General information

NPI: 1124719489
Provider Name (Legal Business Name): KIMBERLY VAZQUEZ-CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CASIA
SAN JUAN PR
00921-3200
US

IV. Provider business mailing address

10 CALLE CASIA
SAN JUAN PR
00921-3200
US

V. Phone/Fax

Practice location:
  • Phone: 787-320-1402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number37844-R
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: