MEDICARE: CARLOS ALBERTO VAQUERO M.D.

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	207R00000X	Internal Medicine Physician	A-180694	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A-180694	OTHER	CA	CALIFORNIA MEDICAL LICENSE

General Provider Information

NPI Number	:	1134782717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS ALBERTO VAQUERO M.D.

Provider Business Mailing Address
First Line	:	9375 SAN FERNANDO RD
Second Line	:
City	:	SUN VALLEY
State	:	CA
Zip	:	91352-1418
Country	:	US
Telephone Number	:	818-768-3000
Fax Number	:	818-797-7178

Provider Business Practice Location Address
First Line	:	9375 SAN FERNANDO RD
Second Line	:
City	:	SUN VALLEY
State	:	CA
Zip	:	91352-1428
Country	:	US
Telephone Number	:	818-768-3000
Fax Number	:	818-504-4690

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

Provider Enumeration Date	:	04/18/2019
Last Update Date	:	08/23/2022

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