Provider Demographics
NPI:1972551851
Name:VACCARO, MARK CLAYTON (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CLAYTON
Last Name:VACCARO
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 1:6304 BRYANT CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73122-7000
Mailing Address - Country:US
Mailing Address - Phone:405-722-8052
Mailing Address - Fax:
Practice Address - Street 1:6304 BRYANT CT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73122-7000
Practice Address - Country:US
Practice Address - Phone:405-722-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F65520Medicare UPIN