Provider Demographics
NPI:1942295308
Name:VACLAW, MICHAEL RYAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:VACLAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 SE ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006
Mailing Address - Country:US
Mailing Address - Phone:918-331-9979
Mailing Address - Fax:918-331-2346
Practice Address - Street 1:4150 SE ADAMS RD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74104-8410
Practice Address - Country:US
Practice Address - Phone:918-331-9979
Practice Address - Fax:918-331-2346
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK19519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100255000AMedicaid
OK100230530AMedicaid
OK100230530AMedicaid