Healthcare Provider Details

I. General information

NPI: 1659341287
Provider Name (Legal Business Name): JOSE LUIS MORALES VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSE LUIS MORALES VAZQUEZ M.D.

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 PHILLIS BLVD
MYRTLE BEACH SC
29577-1560
US

IV. Provider business mailing address

3381 PHILLIS BLVD
MYRTLE BEACH SC
29577-1560
US

V. Phone/Fax

Practice location:
  • Phone: 843-477-0177
  • Fax:
Mailing address:
  • Phone: 843-477-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number15082
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: