Provider Demographics
NPI:1922043579
Name:VACLAVIK, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:VACLAVIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:193 W SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-6239
Mailing Address - Country:US
Mailing Address - Phone:732-897-0200
Mailing Address - Fax:732-897-0263
Practice Address - Street 1:1945 HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4859
Practice Address - Country:US
Practice Address - Phone:732-897-0200
Practice Address - Fax:732-897-0263
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08402900207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ135349Medicare UPIN