Provider Demographics
NPI:1407055114
Name:VACA, LUIS (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
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:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-0765
Mailing Address - Country:US
Mailing Address - Phone:888-685-3915
Mailing Address - Fax:
Practice Address - Street 1:1623 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6528
Practice Address - Country:US
Practice Address - Phone:352-401-8817
Practice Address - Fax:352-401-8822
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130404112085N0700X
TXQ10442085R0202X
FLME1382262085N0700X
MEEC071074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200124410Medicaid