Provider Demographics
NPI:1326572637
Name:VACA, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:VACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 COLUMBUS AVE APT 7K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5929
Mailing Address - Country:US
Mailing Address - Phone:917-330-5484
Mailing Address - Fax:
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:609-303-4010
Practice Address - Fax:609-537-6168
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11278900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine