Healthcare Provider Details

I. General information

NPI: 1386740264
Provider Name (Legal Business Name): KIMBERLY A VACCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 CLEVELAND RD
SANDUSKY OH
44870-4200
US

IV. Provider business mailing address

PO BOX 901874
CLEVELAND OH
44190-1874
US

V. Phone/Fax

Practice location:
  • Phone: 216-383-0100
  • Fax: 216-383-6481
Mailing address:
  • Phone: 216-383-6480
  • Fax: 216-383-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35071486
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: