Provider Demographics
NPI:1518035054
Name:VAZQUEZ, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
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 1:1499 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2603
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-724-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053567207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI450327810Medicaid
JV053567OtherCHAMPUS-CHAMPUS
JV053567OtherCOMMERCIAL-COMMERCIAL NUMBER
GA003141369AMedicaid
440Q263940OtherBLUE CROSS-BLUE CROSS
GA52609049 001OtherBCBS OF GEORGIA
0Q26394025Medicare ID - Type Unspecified
GA52609049 001OtherBCBS OF GEORGIA
GA003141369AMedicaid