Healthcare Provider Details

I. General information

NPI: 1093981607
Provider Name (Legal Business Name): JUAN GABRIEL VASQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2008
Last Update Date: 07/30/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 RIVERTOWN POINT CT SW
GRANDVILLE MI
49418-3076
US

IV. Provider business mailing address

3434 RIVERTOWN POINT CT SW
GRANDVILLE MI
49418-3076
US

V. Phone/Fax

Practice location:
  • Phone: 616-257-3344
  • Fax: 616-257-1491
Mailing address:
  • Phone: 616-257-3344
  • Fax: 616-257-1491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5601102220
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number5601102220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: