Healthcare Provider Details

I. General information

NPI: 1275549636
Provider Name (Legal Business Name): MARISSA VASQUEZ MACHUCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA VASQUEZ MD

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W 7TH ST STE S270-D
LOS ANGELES CA
90017-3768
US

IV. Provider business mailing address

700 W 7TH ST STE S270-D
LOS ANGELES CA
90017-3768
US

V. Phone/Fax

Practice location:
  • Phone: 213-409-6688
  • Fax: 213-988-8390
Mailing address:
  • Phone: 213-409-6688
  • Fax: 213-988-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA89338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: