Healthcare Provider Details

I. General information

NPI: 1114176278
Provider Name (Legal Business Name): ANZHELIKA VACCARO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OAKLAND AVE SUITE 101
PORT JEFFERSON NY
11777-2130
US

IV. Provider business mailing address

825 E GATE BLVD STE 111
GARDEN CITY NY
11530-2136
US

V. Phone/Fax

Practice location:
  • Phone: 631-828-7100
  • Fax: 631-828-7171
Mailing address:
  • Phone: 516-804-5200
  • Fax: 516-240-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number252029
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: