Provider Demographics
NPI:1528129640
Name:VACIK, JONATHAN D (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:VACIK
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 1:60 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 GROTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1168
Practice Address - Country:US
Practice Address - Phone:978-784-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12824207PE0004X
MA220308207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110039191AMedicaid
NHP00398719OtherRAILROAD MEDICARE
MA110039191AMedicaid
NH01Y008914NH02OtherANTHEM
AA79992OtherHARVARD PILGRIM
NHRE8431Medicare PIN
MA2081768Medicaid
AA79992OtherHARVARD PILGRIM