Provider Demographics
NPI:1588664874
Name:VACLAV, JOYCE K (DO)
Entity Type:Individual
Prefix:DR
First Name:JOYCE
Middle Name:K
Last Name:VACLAV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25803 DRESCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1602
Mailing Address - Country:US
Mailing Address - Phone:440-934-6135
Mailing Address - Fax:440-934-6147
Practice Address - Street 1:25803 DRESCHFIELD AVE
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-1602
Practice Address - Country:US
Practice Address - Phone:734-692-6693
Practice Address - Fax:734-692-6693
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009390208M00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1158211544OtherBCBS
MI1588664874Medicaid
MI4634734Medicaid
MIP00010001OtherMEDICARE PTAN WAYNE COUNTY
MIP00040001OtherMEDICARE PTAN MONROE COUNTY
MI00421OtherAETNA
MI4634734Medicaid