Provider Demographics
NPI:1114783222
Name:VAZQUEZ, PETER ALEXANDER JR (ABOC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ALEXANDER
Last Name:VAZQUEZ
Suffix:JR
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 MAPLE AVE W
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4226
Mailing Address - Country:US
Mailing Address - Phone:703-470-8274
Mailing Address - Fax:
Practice Address - Street 1:519 MAPLE AVE W
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4226
Practice Address - Country:US
Practice Address - Phone:703-470-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004529156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician