Provider Demographics
NPI:1023774494
Name:VASQUEZ, RANDY DIAZ (DPT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:DIAZ
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 PAESANOS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1254
Mailing Address - Country:US
Mailing Address - Phone:210-399-4836
Mailing Address - Fax:210-399-1821
Practice Address - Street 1:8403 STATE HIGHWAY 151 STE 111
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2055
Practice Address - Country:US
Practice Address - Phone:210-399-4836
Practice Address - Fax:210-399-1821
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1354722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1354722OtherPT LICENSE #