Basic Information
Provider Information | |||||||||
NPI: | 1164404257 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AZZARA | ||||||||
FirstName: | VINCENT | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14429 REFLECTION LAKES DR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397705465 | ||||||||
FaxNumber: | 0000000000 | ||||||||
Practice Location | |||||||||
Address1: | 14429 REFLECTION LAKES DR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397705465 | ||||||||
FaxNumber: | 0000000000 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2005 | ||||||||
LastUpdateDate: | 01/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS5451 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 15629 | 01 | FL | STAYWELL | OTHER | 055936900 | 05 | FL |   | MEDICAID | 000013683G | 01 | FL | HUMANA | OTHER | 80533 | 01 | FL | BC/BS OF FLORIDA | OTHER | 104456 | 01 | FL | AVMED | OTHER |