Basic Information
| Provider Information | |||||||||
| NPI: | 1316027659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAX | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | LOCKBOX #7642 | ||||||||
| Address2: | PO BOX 8500 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818115 | ||||||||
| FaxNumber: | 8132818656 | ||||||||
| Practice Location | |||||||||
| Address1: | 12502 USF PINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336129411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139757130 | ||||||||
| FaxNumber: | 8139757129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | M2491 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 176190001 | 05 | TX | MEDICAID |