Provider Demographics
NPI:1982766697
Name:VAZ, GERALDINE
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:VAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2897
Practice Address - Country:US
Practice Address - Phone:718-206-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02199580Medicaid
NY02199580Medicaid
NYG40063Medicare UPIN