Provider Demographics
NPI:1093918658
Name:VAZQUEZ, BENJAMIN G (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:G
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:PO BOX 5679
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405
Mailing Address - Country:US
Mailing Address - Phone:541-485-7546
Mailing Address - Fax:541-345-5254
Practice Address - Street 1:4765 VILLAGE PLAZA LOOP
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-485-7546
Practice Address - Fax:541-345-5254
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103786207N00000X
WAMD60286336207N00000X
ORMD179361207N00000X
AZ48763207ND0900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500715739Medicaid
AZ926718Medicaid
AZ9268718Medicaid
AZZ168871Medicare PIN
AZ4343815OtherFIRST HEALTH COVENTRY
AZ9158681OtherAETNA