Provider Demographics
NPI:1790805026
Name:VAZQUEZ, MARY ANNETTE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNETTE
Last Name:VAZQUEZ
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 1:23 ALEXANDER DR
Mailing Address - Street 2:
Mailing Address - City:TUXEDO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:10987-4762
Mailing Address - Country:US
Mailing Address - Phone:845-753-9820
Mailing Address - Fax:
Practice Address - Street 1:40 JON BARRETT RD
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:NY
Practice Address - Zip Code:12563-2164
Practice Address - Country:US
Practice Address - Phone:845-878-9078
Practice Address - Fax:845-878-6139
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223924208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0230J1Medicare ID - Type Unspecified
NYH87413Medicare UPIN