Provider Demographics
NPI:1386683571
Name:VAZQUEZ, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name: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:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-335-1936
Practice Address - Street 1:2 WEST FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-335-1936
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45795207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G457950Medicaid
CA00G457950Medicaid