Provider Demographics
NPI:1457474728
Name:VICENCIO, ANTONIO SISON III (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:SISON
Last Name:VICENCIO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 354339
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-4339
Mailing Address - Country:US
Mailing Address - Phone:386-586-3466
Mailing Address - Fax:386-586-3467
Practice Address - Street 1:21 HOSPITAL DR
Practice Address - Street 2:SUITE 230
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2452
Practice Address - Country:US
Practice Address - Phone:386-586-3466
Practice Address - Fax:386-586-3467
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2010-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME89537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43263OtherBC/BS
NY01156032Medicaid
NY01156032Medicaid
FL43263OtherBC/BS