Provider Demographics
NPI:1134120421
Name:VAZQUEZ, EMILIO J (MD)
Entity type:Individual
Prefix:
First Name:EMILIO
Middle Name:J
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4402 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-425-5500
Practice Address - Fax:260-425-5505
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048856A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080118012OtherRAILROAD MEDICARE
IN9081OtherPHYSICIANS HEALTH PLAN
IN000000191942OtherBC/BS
IN200169800Medicaid
IL000000081113OtherANTHEM
IN000000191942OtherBC/BS
IN200169800Medicaid
IL000000081113OtherANTHEM