Provider Demographics
NPI:1245397694
Name:GOMEZ-VAZQUEZ, ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:GOMEZ-VAZQUEZ
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 1:7215 MCPHERSON RD
Mailing Address - Street 2:STE.115
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6554
Mailing Address - Country:US
Mailing Address - Phone:956-724-3375
Mailing Address - Fax:956-724-2575
Practice Address - Street 1:7215 MCPHERSON RD
Practice Address - Street 2:STE.115
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6554
Practice Address - Country:US
Practice Address - Phone:956-724-3375
Practice Address - Fax:956-724-2575
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033629901Medicaid
TX00GL38Medicare ID - Type Unspecified
TX033629901Medicaid