Provider Demographics
NPI:1659341287
Name:MORALES VAZQUEZ, JOSE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:MORALES VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:LUIS
Other - Last Name:MORALES VAZQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3381 PHILLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1560
Mailing Address - Country:US
Mailing Address - Phone:843-477-0177
Mailing Address - Fax:
Practice Address - Street 1:3381 PHILLIS BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1560
Practice Address - Country:US
Practice Address - Phone:843-477-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15082207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR15082OtherSTATE LICENSE
PR15082OtherSTATE LICENSE
PRBM8705634OtherDEA
PR1-02903Medicare UPIN