Healthcare Provider Details

I. General information

NPI: 1013387562
Provider Name (Legal Business Name): SHARI VASQUEZ DIRECTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MAILSTOP #68
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

5971 VENICE BLVD
LOS ANGELES CA
90034-1713
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2122
  • Fax:
Mailing address:
  • Phone: 323-857-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA137324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: