Provider Demographics
NPI:1043215650
Name:DESTASIO, VINCENT F (DO)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:F
Last Name:DESTASIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1851 HOOPER AVE
Mailing Address - Street 2:STA
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8150
Mailing Address - Country:US
Mailing Address - Phone:732-255-6566
Mailing Address - Fax:732-255-3085
Practice Address - Street 1:1851 HOOPER AVE
Practice Address - Street 2:STA
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8150
Practice Address - Country:US
Practice Address - Phone:732-255-6566
Practice Address - Fax:732-255-3085
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMB51894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD04846300OtherCDS
NJ5453208Medicaid
NJ5453208Medicaid
NJD04846300OtherCDS
NJ5453208Medicaid