Provider Demographics
NPI:1235151424
Name:VASCONEZ, LUIS O (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:O
Last Name:VASCONEZ
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 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:
Practice Address - Street 1:619 19TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL123992086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000014647Medicaid
AL000014647OtherBLUE CROSS
AL009932092Medicaid
AL051529687OtherBLUE CROSS
ALA47233OtherVIVA
AL051529687OtherBLUE CROSS
AL000014647Medicaid