Basic Information
| Provider Information | |||||||||
| NPI: | 1558999458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9856 PALACE GREEN WAY | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221816097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579532339 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104496500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2020 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | N | Other Service Providers | Military Health Care Provider | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | 2021-02554 | NC | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.