Basic Information
| Provider Information | |||||||||
| NPI: | 1962152231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ORTIZ-VAZQUEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | GABRIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1342 W CULLERTON ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606083114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874850817 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE BLDG 105 | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166462 | ||||||||
| FaxNumber: | 7082161249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 125.079321 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.