Provider Demographics
NPI:1063491108
Name:VAZQUEZ, HIRAM (MD)
Entity Type:Individual
Prefix:
First Name:HIRAM
Middle Name:
Last Name:VAZQUEZ
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 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:3217 MABEL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4022
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-631-9126
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07162R207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1382426Medicaid
LA54378Medicare PIN
LAB65221Medicare UPIN