Provider Demographics
NPI:1578634614
Name:VAZQUEZ, RAPHAEL LUIS (MD)
Entity type:Individual
Prefix:PROF
First Name:RAPHAEL
Middle Name:LUIS
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 CORNELIA DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-3906
Mailing Address - Country:US
Mailing Address - Phone:203-542-5184
Mailing Address - Fax:203-542-5184
Practice Address - Street 1:285 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1206
Practice Address - Country:US
Practice Address - Phone:212-927-0060
Practice Address - Fax:212-923-3359
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135505174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00385488Medicaid
NY18A831Medicare ID - Type UnspecifiedPART B CARRIER