Provider Demographics
NPI:1922629450
Name:VAZQUEZ, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 S 3200 W STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-2887
Mailing Address - Country:US
Mailing Address - Phone:801-414-2261
Mailing Address - Fax:
Practice Address - Street 1:7625 S 3200 W STE 2
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-2887
Practice Address - Country:US
Practice Address - Phone:801-414-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist