Healthcare Provider Details

I. General information

NPI: 1093917627
Provider Name (Legal Business Name): PETRA VACLAVKOVA MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PARKWAY
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

PO BOX 64262
BALTIMORE MD
21264-4262
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1000
  • Fax:
Mailing address:
  • Phone: 443-481-6550
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD70524
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: