Provider Demographics
NPI:1023216470
Name:VINCENT, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:VINCENT
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 1:7398 W. DESOTO RD
Mailing Address - Street 2:
Mailing Address - City:WALLS
Mailing Address - State:MS
Mailing Address - Zip Code:38680
Mailing Address - Country:US
Mailing Address - Phone:662-781-1289
Mailing Address - Fax:
Practice Address - Street 1:8573 CORDES CIR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-3317
Practice Address - Country:US
Practice Address - Phone:901-754-6733
Practice Address - Fax:901-754-7808
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02495174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist