Provider Demographics
NPI:1417542416
Name:STITH, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:STITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13732 SMARTY JONES DR
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72142-9547
Mailing Address - Country:US
Mailing Address - Phone:501-647-0522
Mailing Address - Fax:
Practice Address - Street 1:13732 SMARTY JONES DR
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:AR
Practice Address - Zip Code:72142-9547
Practice Address - Country:US
Practice Address - Phone:501-647-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR934432767172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR934432767OtherDRIVER