Healthcare Provider Details

I. General information

NPI: 1356322473
Provider Name (Legal Business Name): JAIME A VAZQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 OFFICERS ROW
VANCOUVER WA
98661-3836
US

IV. Provider business mailing address

PO BOX 65252
VANCOUVER WA
98665-0009
US

V. Phone/Fax

Practice location:
  • Phone: 360-529-0667
  • Fax:
Mailing address:
  • Phone: 360-529-0667
  • Fax: 503-222-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number41020
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number41020
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: