Provider Demographics
NPI:1942245295
Name:VAZQUEZ, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332
Mailing Address - Country:US
Mailing Address - Phone:361-664-2440
Mailing Address - Fax:361-664-6467
Practice Address - Street 1:614 FURMAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2325
Practice Address - Country:US
Practice Address - Phone:361-882-9278
Practice Address - Fax:361-882-9279
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2518207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49388Medicare UPIN
TX8F2367Medicare ID - Type Unspecified