Provider Demographics
NPI:1760407084
Name:VASQUEZ, LUIS ANTONIO (PAC)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANTONIO
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 FORT WASHINGTON AVE
Mailing Address - Street 2:FORT WASHINGTON MEDICALL OFFICE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4711
Mailing Address - Country:US
Mailing Address - Phone:212-927-0013
Mailing Address - Fax:212-927-0014
Practice Address - Street 1:66 FORT WASHINGTON AVE
Practice Address - Street 2:FORT WASHINGTON MEDICALL OFFICE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4711
Practice Address - Country:US
Practice Address - Phone:212-927-0013
Practice Address - Fax:212-927-0014
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009723-1173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine