Healthcare Provider Details

I. General information

NPI: 1891730842
Provider Name (Legal Business Name): EDUARDO RUEDA VASQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 COMMERCE PARK DR SUITE 110
WILLIAMSPORT PA
17701-5475
US

IV. Provider business mailing address

320 HIGHLAND DR P.O. BOX 597
MOUNTVILLE PA
17554-1232
US

V. Phone/Fax

Practice location:
  • Phone: 570-323-6944
  • Fax: 570-323-4529
Mailing address:
  • Phone: 717-285-7121
  • Fax: 717-285-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD438359
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18868
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101048597
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number223712
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31332
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: