Provider Demographics
NPI:1407896574
Name:VACKER, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:VACKER
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 1:4801 S UNIVERSITY DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3839
Mailing Address - Country:US
Mailing Address - Phone:954-434-1705
Mailing Address - Fax:
Practice Address - Street 1:4801 S UNIVERSITY DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3839
Practice Address - Country:US
Practice Address - Phone:954-434-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25662100Medicaid
FL94224CMedicare PIN
FLA49756Medicare UPIN