Healthcare Provider Details

I. General information

NPI: 1972551851
Provider Name (Legal Business Name): MARK CLAYTON VACCARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6304 BRYANT CT
OKLAHOMA CITY OK
73122-7000
US

IV. Provider business mailing address

6304 BRYANT CT
OKLAHOMA CITY OK
73122-7000
US

V. Phone/Fax

Practice location:
  • Phone: 405-722-8052
  • Fax:
Mailing address:
  • Phone: 405-722-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20489
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: