Provider Demographics
NPI:1134102692
Name:VAZQUEZ, MARIETTA (MD)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
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 1:20 YORK ST
Mailing Address - Street 2:YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FL
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-785-4081
Mailing Address - Fax:203-785-3833
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH CHILDREN'S HOSPITAL, WEST PAVILION, 2ND FL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-4081
Practice Address - Fax:203-785-3833
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0362032080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001362037Medicaid
CT370001129Medicare ID - Type Unspecified
G51195Medicare UPIN