Provider Demographics
NPI:1568402725
Name:VAZQUEZ-MORENO, VICTOR M (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:M
Last Name:VAZQUEZ-MORENO
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 1:3211 CALLE RIO GUAYABO
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-9123
Mailing Address - Country:US
Mailing Address - Phone:787-598-2780
Mailing Address - Fax:
Practice Address - Street 1:3211 CALLE RIO GUAYABO
Practice Address - Street 2:
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-9123
Practice Address - Country:US
Practice Address - Phone:787-598-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI471400202084P0800X, 2084P0804X
FLME982662084P0800X, 2084P0804X
PR168542084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3455900Medicaid
WI3455900Medicaid