Healthcare Provider Details

I. General information

NPI: 1528354792
Provider Name (Legal Business Name): LOUIS VAICKUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 06/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 FRANKLIN RODGERS RD
HINGHAM MA
02043-2664
US

IV. Provider business mailing address

22 FRANKLIN RODGERS RD
HINGHAM MA
02043-2664
US

V. Phone/Fax

Practice location:
  • Phone: 781-740-9028
  • Fax:
Mailing address:
  • Phone: 781-740-9028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number176571-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: