Provider Demographics
NPI:1366063984
Name:MALDONADO-VAZQUEZ, EZEQUIEL
Entity type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:MALDONADO-VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 DEAN ST STE 800O
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-4821
Mailing Address - Country:US
Mailing Address - Phone:217-778-6644
Mailing Address - Fax:
Practice Address - Street 1:2325 DEAN ST STE 800O
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4821
Practice Address - Country:US
Practice Address - Phone:331-442-5140
Practice Address - Fax:217-954-0135
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38013547111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor