Healthcare Provider Details

I. General information

NPI: 1164629531
Provider Name (Legal Business Name): MICHELLE VASQUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 WEST ST SUITE 311
PERU IL
61354-2763
US

IV. Provider business mailing address

1305 6TH ST
PERU IL
61354-2759
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-9214
  • Fax: 815-223-9322
Mailing address:
  • Phone: 815-780-5030
  • Fax: 815-780-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036124821
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036124821
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: