Provider Demographics
NPI:1407838642
Name:VINING, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:VINING
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Gender:M
Credentials:MD
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Mailing Address - Street 1:UMASS MEMORIAL HEALTH
Mailing Address - Street 2:55 LAKE AVENUE NORTH
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655
Mailing Address - Country:US
Mailing Address - Phone:774-442-5139
Mailing Address - Fax:774-443-2280
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-2853
Practice Address - Fax:508-856-1042
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-09-20
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Provider Licenses
StateLicense IDTaxonomies
MA205146208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0129780Medicaid
MAH40891Medicare UPIN
MAA3259101Medicare PIN