Healthcare Provider Details

I. General information

NPI: 1588664874
Provider Name (Legal Business Name): JOYCE K VACLAV DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25803 DRESCHFIELD AVE
GROSSE ILE MI
48138-1602
US

IV. Provider business mailing address

25803 DRESCHFIELD AVE
GROSSE ILE MI
48138-1602
US

V. Phone/Fax

Practice location:
  • Phone: 734-692-6693
  • Fax: 734-692-6693
Mailing address:
  • Phone: 440-934-6135
  • Fax: 440-934-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number5101009390
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number5101009390
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: