Provider Demographics
NPI:1316172471
Name:VAZQUEZ, RUBEN MARK (IDMT)
Entity type:Individual
Prefix:
First Name:RUBEN
Middle Name:MARK
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 MUNSS / IDMT
Mailing Address - Street 2:UNIT 8150
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09719-0001
Mailing Address - Country:US
Mailing Address - Phone:00321-134-9410
Mailing Address - Fax:
Practice Address - Street 1:PSC 123 BOX 84
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09719-9998
Practice Address - Country:US
Practice Address - Phone:00321-134-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians