Healthcare Provider Details

I. General information

NPI: 1942295308
Provider Name (Legal Business Name): MICHAEL RYAN VACLAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 SE ADAMS RD
BARTLESVILLE OK
74104-8410
US

IV. Provider business mailing address

4150 SE ADAMS RD
BARTLESVILLE OK
74006
US

V. Phone/Fax

Practice location:
  • Phone: 918-331-9979
  • Fax: 918-331-2346
Mailing address:
  • Phone: 918-331-9979
  • Fax: 918-331-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19519
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: