Healthcare Provider Details

I. General information

NPI: 1750364881
Provider Name (Legal Business Name): JUAN ANGEL VASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 ROSE LN
WICKENBURG AZ
85390-1448
US

IV. Provider business mailing address

523 ROSE LN
WICKENBURG AZ
85390-1448
US

V. Phone/Fax

Practice location:
  • Phone: 286-668-1833
  • Fax:
Mailing address:
  • Phone: 928-668-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number47893
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57599
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: