Healthcare Provider Details

I. General information

NPI: 1366446726
Provider Name (Legal Business Name): JEFFREY L VACIRCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ROUTE 112 BLDG 4
PORT JEFFERSON STATION NY
11776-8055
US

IV. Provider business mailing address

1500 ROUTE 112 BLDG 4
PORT JEFFERSON STATION NY
11776-8055
US

V. Phone/Fax

Practice location:
  • Phone: 631-574-8354
  • Fax: 631-509-6559
Mailing address:
  • Phone: 631-574-8354
  • Fax: 631-509-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number222234
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: