Provider Demographics
NPI:1144776865
Name:SANTIAGO VAZQUEZ, MARELY (MD)
Entity Type:Individual
Prefix:
First Name:MARELY
Middle Name:
Last Name:SANTIAGO 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:PLAZA ONCE H20
Mailing Address - Street 2:CAMBRIDGE PARK
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-1452
Mailing Address - Country:US
Mailing Address - Phone:787-237-5414
Mailing Address - Fax:
Practice Address - Street 1:DERMAGALLERY
Practice Address - Street 2:COND PALMANOVA PLAZA APT C 120
Practice Address - City:PALMAS DEL MAR, HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-0079
Practice Address - Country:US
Practice Address - Phone:787-718-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21880207N00000X, 207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1144776865Medicaid
PR21880OtherSTATE LIC