Provider Demographics
NPI:1730484908
Name:VAZQUEZ M.D., JORGE SALVADOR (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:SALVADOR
Last Name:VAZQUEZ M.D.
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 1:12214 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1910
Mailing Address - Country:US
Mailing Address - Phone:703-490-8216
Mailing Address - Fax:703-497-1547
Practice Address - Street 1:12214 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-1910
Practice Address - Country:US
Practice Address - Phone:703-490-8216
Practice Address - Fax:703-497-1547
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12669208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice