Provider Demographics
NPI:1366911471
Name:GOMEZ VIZCARRA, JORGE MANUEL (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MANUEL
Last Name:GOMEZ VIZCARRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:1100 SW SAINT LUCIE WEST BLVD STE 209
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1735
Practice Address - Country:US
Practice Address - Phone:772-204-8889
Practice Address - Fax:772-204-8895
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21111208D00000X
FLACN1356208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111375300Medicaid