Healthcare Provider Details

I. General information

NPI: 1295668689
Provider Name (Legal Business Name): GUSTAVO VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 CAMELIA LN
MANTECA CA
95336-3658
US

IV. Provider business mailing address

641 CAMELIA LN
MANTECA CA
95336-3658
US

V. Phone/Fax

Practice location:
  • Phone: 209-640-5668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1253454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: