Healthcare Provider Details

I. General information

NPI: 1275834269
Provider Name (Legal Business Name): ALFONSO RALPH VACCARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-5030
  • Fax: 215-707-3494
Mailing address:
  • Phone: 215-707-5030
  • Fax: 215-707-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD419365
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: