Healthcare Provider Details

I. General information

NPI: 1497797401
Provider Name (Legal Business Name): ANTHONY C VACCA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/11/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST STE A
GREENVILLE OH
45331-1396
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 375-472-2129
  • Fax: 937-547-3066
Mailing address:
  • Phone: 765-935-8802
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036105971
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036105971
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036105971
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number02004966A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number34.005077
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: