Basic Information
| Provider Information | |||||||||
| NPI: | 1518035054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067246100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067246100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301053567 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 4301053567 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 450327810 | 05 | MI | MEDICAID | JV053567 | 01 | CHAMPUS-CHAMPUS | OTHER | JV053567 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 003141369A | 05 | GA | MEDICAID | 440Q263940 | 01 | BLUE CROSS-BLUE CROSS | OTHER | 52609049 001 | 01 | GA | BCBS OF GEORGIA | OTHER |