Provider Demographics
NPI:1548588833
Name:VAZQUEZ, GERARDO (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
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 1:440 RAYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:9849 KENWORTHY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4402
Practice Address - Country:US
Practice Address - Phone:915-215-5500
Practice Address - Fax:915-757-0720
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8560207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00000Medicaid
TX11111Medicaid