Healthcare Provider Details

I. General information

NPI: 1740393453
Provider Name (Legal Business Name): VIDAL VAZQUEZ SANTANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 PONCE DE LEON AVE. PDA.23 SUITE 1105 FIRST BANK BUILDING
SANTURCE PR
00910
US

IV. Provider business mailing address

PO BOX 363003
SAN JUAN PR
00936-3003
US

V. Phone/Fax

Practice location:
  • Phone: 787-977-0707
  • Fax: 787-977-0708
Mailing address:
  • Phone: 787-977-0707
  • Fax: 787-977-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number8049
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: