Provider Demographics
NPI:1447218466
Name:HERBST, VINCENT P (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:HERBST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 CAMPBELL ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3166
Mailing Address - Country:US
Mailing Address - Phone:570-322-1600
Mailing Address - Fax:570-322-6160
Practice Address - Street 1:904 CAMPBELL ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3166
Practice Address - Country:US
Practice Address - Phone:570-322-1600
Practice Address - Fax:570-322-6160
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA027240E207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010585600001Medicaid
PA412459Medicare ID - Type Unspecified
PAB41383Medicare UPIN