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General NPI Number Information
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NPI Number | 1366911471
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Entity Type | Individual
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Provider Name | JORGE MANUEL GOMEZ VIZCARRA MD
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Gender | Male
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Dates
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Enumeration Date | 11/19/2018
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Last Update Date | 03/28/2025
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Provider Practice Location Address
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Address Line | 1100 SW SAINT LUCIE WEST BLVD STE 209
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1735
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Country | US
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Telephone | 772-204-8889
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Fax | 772-204-8895
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Provider Business Mailing Address
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Address Line | 5400 PINEHURST DR
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City | SPRING HILL
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State | FL
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Zip | 34606-3833
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Country | US
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Telephone | 352-277-5348
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Fax | 352-606-2857
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 21111
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ACN1356
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License Number State | FL
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