Provider Demographics
NPI:1396788477
Name:VAZQUEZ, LOURDES (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
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:PO BOX 367083
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-7083
Mailing Address - Country:US
Mailing Address - Phone:787-728-6093
Mailing Address - Fax:787-728-6093
Practice Address - Street 1:65 INFANTRY STATION
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00929-2093
Practice Address - Country:US
Practice Address - Phone:787-728-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11576208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG40946Medicare UPIN