Basic Information
| Provider Information | |||||||||
| NPI: | 1548588833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | GERARDO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 RAYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799051613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154480 | ||||||||
| FaxNumber: | 9152155386 | ||||||||
| Practice Location | |||||||||
| Address1: | 9849 KENWORTHY ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799244402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152155500 | ||||||||
| FaxNumber: | 9157570720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2010 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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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 | 207QS0010X | P8560 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | P8560 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 05 | TX | MEDICAID | 11111 | 05 | TX | MEDICAID |