Healthcare Provider Details

I. General information

NPI: 1093743098
Provider Name (Legal Business Name): DEETTE RAY VASQUES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W MAGNOLIA AVE
FORT WORTH TX
76104-4611
US

IV. Provider business mailing address

800 W MAGNOLIA AVE
FORT WORTH TX
76104-4611
US

V. Phone/Fax

Practice location:
  • Phone: 817-759-7000
  • Fax: 817-759-7027
Mailing address:
  • Phone: 817-759-7000
  • Fax: 817-759-7027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberN5453
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS012961
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberN5453
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: