Healthcare Provider Details

I. General information

NPI: 1861488314
Provider Name (Legal Business Name): STEPHEN VACCAREZZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 MONTROSE RD
ROCKVILLE MD
20852-4119
US

IV. Provider business mailing address

6240 MONTROSE RD
ROCKVILLE MD
20852-4119
US

V. Phone/Fax

Practice location:
  • Phone: 301-231-7111
  • Fax: 301-231-9040
Mailing address:
  • Phone: 301-231-7111
  • Fax: 301-231-9040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD35103
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: