Provider Demographics
NPI:1689622573
Name:VASQUEZ, RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:VASQUEZ
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 1:815 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2212
Mailing Address - Country:US
Mailing Address - Phone:812-336-6008
Mailing Address - Fax:812-339-6947
Practice Address - Street 1:815 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2212
Practice Address - Country:US
Practice Address - Phone:812-336-6008
Practice Address - Fax:812-339-6947
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062063A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200818170OtherMEDICAID GROUP
INP00400660OtherMEDICARE RAILROAD INDIVIDUAL
IN200818170AOtherMEDICAID INDIVIDUAL
IN250940OtherMEDICARE GROUP
IN517966OtherANTHEM GROUP
IN000000517969OtherANTHEM INDIVIDUAL
IN250940AOtherMEDICARE INDIVIDUAL
INP00400660OtherMEDICARE RAILROAD INDIVIDUAL