Provider Demographics
NPI:1780637769
Name:VAZALES, SHERRI S (MD)
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:S
Last Name:VAZALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2345
Mailing Address - Country:US
Mailing Address - Phone:231-392-0421
Mailing Address - Fax:231-935-5885
Practice Address - Street 1:14695 PARK AVE STE A
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074823207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI070015180OtherRR MEDICARE
MI4230205Medicaid
MI0P32670Medicare PIN
MI4230205Medicaid