Healthcare Provider Details

I. General information

NPI: 1649067307
Provider Name (Legal Business Name): KEVIN MICHAEL VACLAVIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 PARK AVE
NEW YORK NY
10028-0921
US

IV. Provider business mailing address

165 E 31ST ST
BROOKLYN NY
11226-5503
US

V. Phone/Fax

Practice location:
  • Phone: 212-371-8460
  • Fax:
Mailing address:
  • Phone: 832-371-3433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: