Healthcare Provider Details

I. General information

NPI: 1861528275
Provider Name (Legal Business Name): ANDREW RICHARD VACLAVIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

1400 VFW PARKWAY VA MEDICAL CENTER
WEST ROXBURY MA
02132
US

V. Phone/Fax

Practice location:
  • Phone: 201-575-5016
  • Fax:
Mailing address:
  • Phone: 201-575-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number250203
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: