Healthcare Provider Details

I. General information

NPI: 1790765063
Provider Name (Legal Business Name): WILLIAM G VAZQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

1303 AZALEA CT STE C
MYRTLE BEACH SC
29577-5765
US

V. Phone/Fax

Practice location:
  • Phone: 843-467-2676
  • Fax:
Mailing address:
  • Phone: 843-467-2676
  • Fax: 843-497-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number055035
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26692
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: