Provider Demographics
NPI:1801209580
Name:VASQUEZ, CHARLES RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RYAN
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1928 SOUTH ST
Mailing Address - Street 2:APT. 2R
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1477
Mailing Address - Country:US
Mailing Address - Phone:763-913-6440
Mailing Address - Fax:
Practice Address - Street 1:3600 SPRUCE ST
Practice Address - Street 2:MALONEY BUILDING, FLOOR 4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4211
Practice Address - Country:US
Practice Address - Phone:215-662-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT206076208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery