Provider Demographics
NPI:1659326403
Name:VACCA, DANTE F (MD)
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:F
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 1:5590 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3019
Mailing Address - Country:US
Mailing Address - Phone:775-323-2080
Mailing Address - Fax:775-323-8216
Practice Address - Street 1:5590 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3019
Practice Address - Country:US
Practice Address - Phone:775-323-2080
Practice Address - Fax:775-323-8216
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5826207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC0499OtherBC/BS
NV880167036A013OtherTRICARE
CAXPY097980Medicaid
NV002016113Medicaid
NVE28557Medicare UPIN
NV002016113Medicaid
CAXPY097980Medicaid