Provider Demographics
NPI:1659477677
Name:VAZQUEZ, ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
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 1:603 S CANAL ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-4256
Mailing Address - Country:US
Mailing Address - Phone:910-642-3700
Mailing Address - Fax:910-642-5146
Practice Address - Street 1:603 S CANAL ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4256
Practice Address - Country:US
Practice Address - Phone:910-642-3700
Practice Address - Fax:910-642-5146
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97011812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891122KMedicaid
NC891122KMedicaid
G67486Medicare UPIN