Provider Demographics
NPI:1083889398
Name:VASQUEZ, TITO L (MD)
Entity Type:Individual
Prefix:DR
First Name:TITO
Middle Name:L
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 1:2600 POST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1258
Mailing Address - Country:US
Mailing Address - Phone:203-292-8119
Mailing Address - Fax:203-292-8120
Practice Address - Street 1:2600 POST RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1258
Practice Address - Country:US
Practice Address - Phone:203-292-8119
Practice Address - Fax:203-292-8120
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0461692086S0122X, 208200000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300000073OtherMEDICARE PTAN