Provider Demographics
NPI:1679675722
Name:VAZQUEZ, LILLIAM ENID
Entity Type:Individual
Prefix:
First Name:LILLIAM
Middle Name:ENID
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705-1886
Mailing Address - Country:US
Mailing Address - Phone:787-735-2445
Mailing Address - Fax:
Practice Address - Street 1:726 JOSE C VAZQUEZ
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-385-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR914208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0053111Medicare ID - Type UnspecifiedMEDICARE
PRP20132Medicare UPIN