Provider Demographics
NPI:1508000670
Name:IMBROGNO, VINCENT MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:MICHAEL
Last Name:IMBROGNO
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 1:2640 ZUCK RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-3151
Mailing Address - Country:US
Mailing Address - Phone:814-838-9555
Mailing Address - Fax:814-835-7776
Practice Address - Street 1:2640 ZUCK RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-3151
Practice Address - Country:US
Practice Address - Phone:814-838-9555
Practice Address - Fax:814-835-7776
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016252207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028650000003Medicaid