Healthcare Provider Details

I. General information

NPI: 1538241930
Provider Name (Legal Business Name): JOHN ANTHONY VACCARO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3124 S 19TH ST STE 320
TACOMA WA
98405-2433
US

IV. Provider business mailing address

3124 S 19TH ST STE 320
TACOMA WA
98405-2433
US

V. Phone/Fax

Practice location:
  • Phone: 253-301-5100
  • Fax: 253-301-5101
Mailing address:
  • Phone: 253-301-5100
  • Fax: 253-301-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number600180340
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: