Provider Demographics
NPI:1669001426
Name:VASQUEZ, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5114 WYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:PLAINSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08536-2035
Mailing Address - Country:US
Mailing Address - Phone:609-815-1172
Mailing Address - Fax:
Practice Address - Street 1:ST. JOSEPH'S UNIVERSITY MEDICAL HOSPITAL 703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503
Practice Address - Country:US
Practice Address - Phone:973-754-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA11891200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program