Provider Demographics
NPI:1457824120
Name:VASQUEZ, MADALYN G (RD)
Entity Type:Individual
Prefix:
First Name:MADALYN
Middle Name:G
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3419
Mailing Address - Country:US
Mailing Address - Phone:201-836-5655
Mailing Address - Fax:201-836-3571
Practice Address - Street 1:870 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3419
Practice Address - Country:US
Practice Address - Phone:201-836-5655
Practice Address - Fax:201-836-3571
Is Sole Proprietor?:No
Enumeration Date:2019-01-05
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86087476133V00000X
133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ473784957Medicaid
NJ473784957OtherBCBS
NJ473784957OtherCIGNA
NJ473784957OtherUNITED HEALTHCARE
NJ473784957OtherOXFORD
NJ473784957OtherAETNA