Provider Demographics
NPI:1366446726
Name:VACIRCA, JEFFREY L (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:VACIRCA
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 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 4
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-574-8354
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:1500 ROUTE 112
Practice Address - Street 2:BLDG 4
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8055
Practice Address - Country:US
Practice Address - Phone:631-574-8354
Practice Address - Fax:631-509-6559
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222234207RH0003X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02521837Medicaid
NY6Z0051Medicare PIN
NY02521837Medicaid