Healthcare Provider Details

I. General information

NPI: 1205880192
Provider Name (Legal Business Name): ROBERT G VACLAV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19020 FORT ST
RIVERVIEW MI
48193-6701
US

IV. Provider business mailing address

19020 FORT ST
RIVERVIEW MI
48193-6701
US

V. Phone/Fax

Practice location:
  • Phone: 734-362-5100
  • Fax: 734-362-5147
Mailing address:
  • Phone: 734-362-5100
  • Fax: 734-362-5147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number5101006380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: