Provider Demographics
NPI:1245434513
Name:VASQUEZ, JOHN DANGCA (IDC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DANGCA
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 SEDGE ST
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-9503
Mailing Address - Country:US
Mailing Address - Phone:910-546-6907
Mailing Address - Fax:
Practice Address - Street 1:3001 6TH ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:910-450-6397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman