Healthcare Provider Details

I. General information

NPI: 1427251594
Provider Name (Legal Business Name): GUSTAVO ADOLFO VASQUEZ RUBIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 10/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4316
US

IV. Provider business mailing address

1015 CHESTNUT ST SUITE 1020
PHILADELPHIA PA
19107-4316
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7785
  • Fax: 215-955-9362
Mailing address:
  • Phone: 215-955-7785
  • Fax: 215-955-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-439046
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD-439046
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: