Provider Demographics
NPI:1417901901
Name:VAZQUEZ CORREA, BERALDO A (MD)
Entity Type:Individual
Prefix:
First Name:BERALDO
Middle Name:A
Last Name:VAZQUEZ CORREA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BERALDO
Other - Middle Name:A
Other - Last Name:VAZQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2764 N GREEN VALLEY PKWY # 376
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2120
Mailing Address - Country:US
Mailing Address - Phone:702-374-6949
Mailing Address - Fax:702-616-0657
Practice Address - Street 1:825 S MAIN STREET
Practice Address - Street 2:#B393
Practice Address - City:TONOPAH
Practice Address - State:NV
Practice Address - Zip Code:89049
Practice Address - Country:US
Practice Address - Phone:775-382-2000
Practice Address - Fax:775-319-4130
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1417901901Medicaid