1417901901 NPI number — BERALDO A VAZQUEZ CORREA MD

Table of content: BERALDO A VAZQUEZ CORREA MD (NPI 1417901901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417901901 NPI number — BERALDO A VAZQUEZ CORREA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAZQUEZ CORREA
Provider First Name:
BERALDO
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAZQUEZ
Provider Other First Name:
BERALDO
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417901901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2764 N GREEN VALLEY PKWY # 376
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89014-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-374-6949
Provider Business Mailing Address Fax Number:
702-616-0657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 S MAIN STREET
Provider Second Line Business Practice Location Address:
#B393
Provider Business Practice Location Address City Name:
TONOPAH
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-382-2000
Provider Business Practice Location Address Fax Number:
775-319-4130
Provider Enumeration Date:
05/20/2006

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: 207R00000X , with the licence number:  5720 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1417901901 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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