Provider Demographics
NPI:1962561936
Name:VOMACKA, MARY ELLEN LOUISE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN LOUISE
Last Name:VOMACKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 SOUTH FIRST STREET
Mailing Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-5079
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:1604 SOUTH FIRST STREET
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-5079
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN367462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1521082OtherUBH
9F414VOOtherBLUE CROSS
1013089OtherPREFERRED ONE
115359OtherUCARE
9F414VOOtherBLUE CROSS