Healthcare Provider Details

I. General information

NPI: 1760407084
Provider Name (Legal Business Name): LUIS ANTONIO VASQUEZ PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 FORT WASHINGTON AVE FORT WASHINGTON MEDICALL OFFICE
NEW YORK NY
10032-4711
US

IV. Provider business mailing address

66 FORT WASHINGTON AVE FORT WASHINGTON MEDICALL OFFICE
NEW YORK NY
10032-4711
US

V. Phone/Fax

Practice location:
  • Phone: 212-927-0013
  • Fax: 212-927-0014
Mailing address:
  • Phone: 212-927-0013
  • Fax: 212-927-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number009723-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: