Provider Demographics
NPI:1568269629
Name:VASQUEZ, MIGUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:VASQUEZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:MRS
Other - First Name:MIGUEL
Other - Middle Name:A
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:412 STORMS RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-1212
Mailing Address - Country:US
Mailing Address - Phone:646-399-1639
Mailing Address - Fax:
Practice Address - Street 1:575 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-2422
Practice Address - Country:US
Practice Address - Phone:347-868-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant