1144776865 NPI number — MARELY SANTIAGO VAZQUEZ MD

Table of content: MARELY SANTIAGO VAZQUEZ MD (NPI 1144776865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144776865 NPI number — MARELY SANTIAGO VAZQUEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANTIAGO VAZQUEZ
Provider First Name:
MARELY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144776865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PLAZA ONCE H20
Provider Second Line Business Mailing Address:
CAMBRIDGE PARK
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00926-1452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-237-5414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DERMAGALLERY
Provider Second Line Business Practice Location Address:
COND PALMANOVA PLAZA APT C 120
Provider Business Practice Location Address City Name:
PALMAS DEL MAR, HUMACAO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00791-0079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-718-7144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  21880 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1144776865 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21880 . This is a "STATE LIC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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