Provider Demographics
NPI:1144780651
Name:VASQUEZ, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8844
Mailing Address - Country:US
Mailing Address - Phone:727-914-0200
Mailing Address - Fax:727-201-8905
Practice Address - Street 1:2201 CENTRAL AVE STE 200
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8844
Practice Address - Country:US
Practice Address - Phone:727-914-0200
Practice Address - Fax:727-201-8905
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME1636252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRZUA0012347622515OtherTRIPLE-S SALUD