Provider Demographics
NPI:1114506987
Name:VAZQUEZ, ALFONSO M
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:M
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81719 DR CARREON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5518
Mailing Address - Country:US
Mailing Address - Phone:760-837-8722
Mailing Address - Fax:760-834-7989
Practice Address - Street 1:81719 DR CARREON BLVD STE B
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5518
Practice Address - Country:US
Practice Address - Phone:760-837-8722
Practice Address - Fax:760-834-7989
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA197337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine