Provider Demographics
NPI:1750539789
Name:VAZQUEZ-BRYAN, JENNIFER K (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:VAZQUEZ-BRYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MCNALLY ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1104
Mailing Address - Country:US
Mailing Address - Phone:845-510-1870
Mailing Address - Fax:845-510-1872
Practice Address - Street 1:6511 SPRING BROOK AVE
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572
Practice Address - Country:US
Practice Address - Phone:845-876-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276666207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04046851Medicaid