Provider Demographics
NPI:1689952590
Name:REALYVASQUEZ, FIDEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FIDEL
Middle Name:
Last Name:REALYVASQUEZ
Suffix:JR
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 1:15 BUSINESS PARK WAY STE 111
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-0959
Mailing Address - Country:US
Mailing Address - Phone:916-387-6929
Mailing Address - Fax:916-387-6977
Practice Address - Street 1:15 BUSINESS PARK WAY STE 111
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-0959
Practice Address - Country:US
Practice Address - Phone:916-387-6929
Practice Address - Fax:916-387-6977
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG332832083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine