Provider Demographics
NPI:1427793447
Name:VAZQUEZ, BANESA KASSANDRA (DO)
Entity type:Individual
Prefix:
First Name:BANESA
Middle Name:KASSANDRA
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 CASSIE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BRYAN DR STE 201
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2157
Practice Address - Country:US
Practice Address - Phone:580-924-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK0549R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program