Healthcare Provider Details

I. General information

NPI: 1326572637
Provider Name (Legal Business Name): CARLOS A VACA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAPITAL WAY
PENNINGTON NJ
08534-2520
US

IV. Provider business mailing address

788 COLUMBUS AVE APT 7K
NEW YORK NY
10025-5929
US

V. Phone/Fax

Practice location:
  • Phone: 609-303-4010
  • Fax: 609-537-6168
Mailing address:
  • Phone: 917-330-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA11278900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number13437
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number312699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: