Provider Demographics
NPI:1578637963
Name:VANCOURT, ROBERT B (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:VANCOURT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-6554
Mailing Address - Country:US
Mailing Address - Phone:614-792-3668
Mailing Address - Fax:614-792-7615
Practice Address - Street 1:9759 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065
Practice Address - Country:US
Practice Address - Phone:614-792-3668
Practice Address - Fax:614-792-7615
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003110213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00320863OtherRAILROAD MEDICARE
OH2298508Medicaid
OHU84354Medicare UPIN
OH4045085Medicare ID - Type Unspecified