Provider Demographics
NPI:1275680266
Name:VINCENT, CHRISTOPHER KELLY (MD PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:KELLY
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BUTLER AVE
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9990
Mailing Address - Country:US
Mailing Address - Phone:304-263-0811
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012387732086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010405670Medicaid
VAP00453908OtherMEDICARE RAILROAD
F30459Medicare UPIN
013326C65Medicare PIN
VA015566L84Medicare PIN