Healthcare Provider Details

I. General information

NPI: 1437387883
Provider Name (Legal Business Name): LUIS VAZQUEZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 E BEARDSLEY RD SUITE 260
PHOENIX AZ
85024-1285
US

IV. Provider business mailing address

2340 E BEARDSLEY RD SUITE 260
PHOENIX AZ
85024-1285
US

V. Phone/Fax

Practice location:
  • Phone: 602-802-8240
  • Fax: 602-802-8245
Mailing address:
  • Phone: 602-802-8240
  • Fax: 602-802-8245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101018092
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number006403
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: