Healthcare Provider Details

I. General information

NPI: 1689635633
Provider Name (Legal Business Name): PASTOR GOMEZ VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 08/06/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 NE LAWRIE TATUM RD
LAWTON OK
73507-3099
US

IV. Provider business mailing address

409 HANNAH AVE.
FLETCHER OK
73541
US

V. Phone/Fax

Practice location:
  • Phone: 580-354-5000
  • Fax:
Mailing address:
  • Phone: 580-277-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301088842
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12082
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME153892
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: