Healthcare Provider Details

I. General information

NPI: 1407055114
Provider Name (Legal Business Name): LUIS VACA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 SW 1ST AVE
OCALA FL
34471-6528
US

IV. Provider business mailing address

PO BOX 765
INDIANAPOLIS IN
46206-0765
US

V. Phone/Fax

Practice location:
  • Phone: 352-401-8817
  • Fax: 352-401-8822
Mailing address:
  • Phone: 888-685-3915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number2013040411
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberQ1044
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME138226
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberEC071074
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: