Provider Demographics
NPI:1255447041
Name:VASQUEZ, MIGUEL (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:VASQUEZ
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 1:243 GREEN VALLEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:243 GREEN VALLEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019
Practice Address - Country:US
Practice Address - Phone:831-728-4595
Practice Address - Fax:831-728-4598
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33076207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
A27030Medicare UPIN
00A330760Medicare ID - Type Unspecified