Healthcare Provider Details

I. General information

NPI: 1538101720
Provider Name (Legal Business Name): JOYCE K VACLAV DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
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: 440-934-6135
  • Fax: 440-934-6147
Mailing address:
  • Phone: 440-934-6135
  • Fax: 440-934-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number5101009390
License Number StateMI

VIII. Authorized Official

Name: DR. JOYCE K VACLAV
Title or Position: OWNER/PHYSICIAN
Credential: DO
Phone: 734-558-8891