Provider Demographics
NPI: | 1134102692 |
---|---|
Name: | VAZQUEZ, MARIETTA (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARIETTA |
Middle Name: | |
Last Name: | VAZQUEZ |
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: | 20 YORK ST |
Mailing Address - Street 2: | YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FL |
Mailing Address - City: | NEW HAVEN |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06510-3220 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-785-4081 |
Mailing Address - Fax: | 203-785-3833 |
Practice Address - Street 1: | 20 YORK ST |
Practice Address - Street 2: | YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FL |
Practice Address - City: | NEW HAVEN |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06510-3220 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-785-4081 |
Practice Address - Fax: | 203-785-3833 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-29 |
Last Update Date: | 2011-04-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 036203 | 2080P0208X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2080P0208X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 001362037 | Medicaid | |
CT | 370001129 | Medicare ID - Type Unspecified | |
G51195 | Medicare UPIN |