Healthcare Provider Details

I. General information

NPI: 1396736906
Provider Name (Legal Business Name): JOSEPH PHILIP VACANTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WRN 1157
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-1725
  • Fax: 617-726-7593
Mailing address:
  • Phone: 617-724-1725
  • Fax: 617-726-7593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number39234
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: