Healthcare Provider Details

I. General information

NPI: 1326076266
Provider Name (Legal Business Name): CARLOS R VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 S BURNSIDE AVE STE 4
GONZALES LA
70737-4634
US

IV. Provider business mailing address

PO BOX 1117
GONZALES LA
70707-1117
US

V. Phone/Fax

Practice location:
  • Phone: 225-647-1947
  • Fax:
Mailing address:
  • Phone: 225-647-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number022083
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number022083
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: