Provider Demographics
NPI:1417179185
Name:E.VICENCIO-QUEVEDO M.D. INC.
Entity Type:Organization
Organization Name:E.VICENCIO-QUEVEDO M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDITA
Authorized Official - Middle Name:E
Authorized Official - Last Name:VICENCIO-QUEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-822-8317
Mailing Address - Street 1:709 E COLORADO BLVD
Mailing Address - Street 2:#160
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2125
Mailing Address - Country:US
Mailing Address - Phone:818-822-8317
Mailing Address - Fax:626-793-7580
Practice Address - Street 1:709 E COLORADO BLVD
Practice Address - Street 2:#160
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2125
Practice Address - Country:US
Practice Address - Phone:818-822-8317
Practice Address - Fax:626-793-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23710207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A237100Medicaid
CAA23710Medicare PIN
CAB49965Medicare UPIN