Provider Demographics
NPI:1750476982
Name:VAZQUEZ, MAGDA (MD)
Entity type:Individual
Prefix:
First Name:MAGDA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 SW 24TH ST
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2643
Mailing Address - Country:US
Mailing Address - Phone:954-467-4822
Mailing Address - Fax:954-760-7798
Practice Address - Street 1:2421 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2613
Practice Address - Country:US
Practice Address - Phone:954-467-4822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN88207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371064500Medicaid
FL371064500Medicaid
FL23263ZMedicare NSC