Provider Demographics
NPI:1073975124
Name:VASQUEZ, ROXANNE (MD)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:VASQUEZ
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 1:17250 BIRCHER ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2408
Mailing Address - Country:US
Mailing Address - Phone:818-368-7753
Mailing Address - Fax:
Practice Address - Street 1:2240 E GONZALES RD STE 140
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-8212
Practice Address - Country:US
Practice Address - Phone:805-981-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-27
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152528174400000X
390200000X
CAA1525282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program