Provider Demographics
NPI:1205880192
Name:VACLAV, ROBERT G (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:VACLAV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19020 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-6701
Mailing Address - Country:US
Mailing Address - Phone:734-362-5100
Mailing Address - Fax:734-362-5147
Practice Address - Street 1:19020 FORT ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-6701
Practice Address - Country:US
Practice Address - Phone:734-362-5100
Practice Address - Fax:734-362-5147
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006380207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H21076OtherBCBSM
MIC4684OtherMCARE
MI3221631Medicaid
MICC33713OtherRR MEDICARE
MI8061647OtherCIGAN
MI125103OtherMERCY CARE CHOICES
MI4037350OtherAETNA
MI292373OtherUHC
MI5101006380OtherPHYSICIAN LICENSE
MIC4684OtherMCARE
MI125103OtherMERCY CARE CHOICES
MIE26700Medicare UPIN