Healthcare Provider Details

I. General information

NPI: 1689622573
Provider Name (Legal Business Name): RICARDO VASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 W 2ND ST
BLOOMINGTON IN
47403-2212
US

IV. Provider business mailing address

815 W 2ND ST
BLOOMINGTON IN
47403-2212
US

V. Phone/Fax

Practice location:
  • Phone: 812-336-6008
  • Fax: 812-339-6947
Mailing address:
  • Phone: 812-336-6008
  • Fax: 812-339-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01062063A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: