Provider Demographics
NPI:1417041526
Name:VACCA, BRIAN DOMENIC (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DOMENIC
Last Name:VACCA
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 1:10928 EAGLE RIVER RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8078
Mailing Address - Country:US
Mailing Address - Phone:907-622-1300
Mailing Address - Fax:
Practice Address - Street 1:10928 EAGLE RIVER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8078
Practice Address - Country:US
Practice Address - Phone:907-622-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51455208100000X
AK103783208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250000816OtherMEDICARE PTAN