Provider Demographics
NPI:1487653002
Name:KIESEL, VINCENT E,C (MDPA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:E,C
Last Name:KIESEL
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S PINELLAS AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3728
Mailing Address - Country:US
Mailing Address - Phone:727-938-1581
Mailing Address - Fax:727-938-1583
Practice Address - Street 1:1200 S PINELLAS AVE
Practice Address - Street 2:STE 1
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3728
Practice Address - Country:US
Practice Address - Phone:727-938-1581
Practice Address - Fax:727-938-1583
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36082207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065659300Medicaid
D57389Medicare UPIN
FL065659300Medicaid