Provider Demographics
NPI:1245721612
Name:VACKETTA, VINCENT GIANNI (DPM)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:GIANNI
Last Name:VACKETTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3294
Mailing Address - Country:US
Mailing Address - Phone:309-691-1400
Mailing Address - Fax:
Practice Address - Street 1:6000 N ALLEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3294
Practice Address - Country:US
Practice Address - Phone:309-691-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016006029213ES0103X, 207X00000X, 207XX0004X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist