Provider Demographics
NPI:1417397076
Name:VINCENT, THOMAS BLAKE (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BLAKE
Last Name:VINCENT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1244
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1244
Mailing Address - Country:US
Mailing Address - Phone:812-465-6202
Mailing Address - Fax:812-474-3622
Practice Address - Street 1:1253 PARIS RD # A
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-4989
Practice Address - Country:US
Practice Address - Phone:270-247-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3058207Q00000X
KY03709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201324850Medicaid
KY7100282830Medicaid
KY7100282830Medicaid