Provider Demographics
NPI:1295796480
Name:ZACHARY, VANCE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:VANCE
Middle Name:EDWARD
Last Name:ZACHARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4420 IRVING BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5915
Mailing Address - Country:US
Mailing Address - Phone:505-727-6300
Mailing Address - Fax:505-727-9588
Practice Address - Street 1:4420 IRVING BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5915
Practice Address - Country:US
Practice Address - Phone:505-727-6300
Practice Address - Fax:505-727-9588
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7610207Q00000X, 207QS0010X
NMMD2015-0091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM401311YR41OtherMEDICARE NUMBER
NM25156772Medicaid
TX098710903Medicaid
NM401311YR41OtherMEDICARE NUMBER
TXB27758Medicare UPIN