Provider Demographics
NPI:1245391986
Name:VASQUEZ, RENE S (MD)
Entity Type:Individual
Prefix:MR
First Name:RENE
Middle Name:S
Last Name:VASQUEZ
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 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:929 N SPRING GARDEN AVE STE 170
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0917
Practice Address - Country:US
Practice Address - Phone:386-738-9144
Practice Address - Fax:877-245-1597
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052042Medicaid
ILD12866Medicare UPIN
IL482011Medicare ID - Type Unspecified