MEDICARE: ERNESTO JUAN VAZQUEZ SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1003639378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERNESTO JUAN VAZQUEZ SR.

Provider Business Mailing Address
First Line	:	RR 4 BOX 26456
Second Line	:
City	:	TOA ALTA
State	:	PR
Zip	:	00953-9465
Country	:	US
Telephone Number	:	787-233-8493
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE SANTA CRUZ, URB # 70
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00956
Country	:	US
Telephone Number	:	787-620-4747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2024
Last Update Date	:	05/12/2026

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