Provider Demographics
NPI:1588611990
Name:VINCENT, MAURICE (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:VINCENT
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 1:380 W CENTRAL AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3066
Mailing Address - Country:US
Mailing Address - Phone:714-482-2775
Mailing Address - Fax:714-482-2779
Practice Address - Street 1:380 W CENTRAL AVE STE 230
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3066
Practice Address - Country:US
Practice Address - Phone:714-482-2775
Practice Address - Fax:714-482-2779
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A544970Medicaid
CAWA54497GMedicare PIN
G41475Medicare UPIN
CAWA54497HMedicare PIN
CAWA54497FMedicare PIN
CAWA54497HMedicare PIN