MEDICARE: EMILIO J VAZQUEZ MD

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	207Q00000X	Family Medicine Physician	01048856A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080118012	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	9081	OTHER	IN	PHYSICIANS HEALTH PLAN
3	000000191942	OTHER	IN	BC/BS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000000081113	OTHER	IL	ANTHEM

General Provider Information

NPI Number	:	1134120421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILIO J VAZQUEZ MD

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4402 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-425-5500
Fax Number	:	260-425-5505

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/12/2022

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Directions to “ EMILIO J VAZQUEZ MD” Practice Location

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