Provider Demographics
NPI:1811422132
Name:VAZQUEZ, SAMUEL IRAN (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:IRAN
Last Name:VAZQUEZ
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 1:55 LAKE AVE N
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1964 PATTERSON DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1434
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03666440208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery