Healthcare Provider Details

I. General information

NPI: 1164473666
Provider Name (Legal Business Name): STEVEN J VACEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 GLENWOOD ST SUITE 500
GLEN ROSE TX
76043-4933
US

IV. Provider business mailing address

409 GLENWOOD ST STE 500 GLEN ROSE HEALTHCARE INC.
GLEN ROSE TX
76043-4933
US

V. Phone/Fax

Practice location:
  • Phone: 254-897-2202
  • Fax: 254-897-1638
Mailing address:
  • Phone: 254-897-2202
  • Fax: 254-897-1638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34587
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ2958
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: