Provider Demographics
NPI:1124128590
Name:VASQUEZ, MARIELA D (MD)
Entity type:Individual
Prefix:
First Name:MARIELA
Middle Name:D
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 1906
Mailing Address - Street 2:821 W FRANK
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902-1906
Mailing Address - Country:US
Mailing Address - Phone:936-639-5474
Mailing Address - Fax:936-639-5487
Practice Address - Street 1:1201 W FRANK
Practice Address - Street 2:MEMORIAL MEDICAL CENTER
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-639-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6787207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8661B0OtherBCBS
8B8098Medicare ID - Type Unspecified
8661B0OtherBCBS