Provider Demographics
NPI:1629625850
Name:VAZQUEZ, IAN JAVIER (LND, RD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JAVIER
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:LND, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LOMAS VERDES
Mailing Address - Street 2:2 J 10 CALLE FLAMBOYAN
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-3429
Mailing Address - Country:US
Mailing Address - Phone:787-662-6348
Mailing Address - Fax:
Practice Address - Street 1:1456 CALLE PROF. AUGUSTO RODRIGUEZ
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-230-7530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2104133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered