Provider Demographics
NPI:1750364881
Name:VASQUEZ, JUAN ANGEL (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:ANGEL
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 1:523 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1448
Mailing Address - Country:US
Mailing Address - Phone:928-668-1833
Mailing Address - Fax:
Practice Address - Street 1:523 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1448
Practice Address - Country:US
Practice Address - Phone:286-668-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47893207R00000X
AZ57599207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34637900Medicaid
WIP00280478OtherRAILROAD MEDICARE
WI34637900Medicaid
WI005116130Medicare ID - Type Unspecified
WI34637900Medicaid
WI13999OtherDEAN
F89163Medicare UPIN