Provider Demographics
NPI:1366495285
Name:VAZALES, BRAD E (MD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:E
Last Name:VAZALES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2390 MITCHELL PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-487-9090
Mailing Address - Fax:231-487-9191
Practice Address - Street 1:2390 MITCHELL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-487-9090
Practice Address - Fax:231-487-9191
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-10-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301073933208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4319099Medicaid
MI780001998OtherRR MEDICARE
MI0N57190Medicare PIN
MI4319099Medicaid