Provider Demographics
NPI:1164629531
Name:VASQUEZ, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VASQUEZ
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 1:1305 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2759
Mailing Address - Country:US
Mailing Address - Phone:815-780-5030
Mailing Address - Fax:815-780-4634
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:SUITE 311
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-223-9214
Practice Address - Fax:815-223-9322
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124821207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL819300027Medicare PIN