1588664874 NPI number — DR. JOYCE K VACLAV DO

Table of content: DR. JOYCE K VACLAV DO (NPI 1588664874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588664874 NPI number — DR. JOYCE K VACLAV DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VACLAV
Provider First Name:
JOYCE
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588664874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25803 DRESCHFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROSSE ILE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48138-1602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-934-6135
Provider Business Mailing Address Fax Number:
440-934-6147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25803 DRESCHFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROSSE ILE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48138-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-692-6693
Provider Business Practice Location Address Fax Number:
734-692-6693
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  5101009390 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 5101009390 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1158211544 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1588664874 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4634734 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00010001 . This is a "MEDICARE PTAN WAYNE COUNTY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00040001 . This is a "MEDICARE PTAN MONROE COUNTY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 00421 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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