Provider Demographics
NPI:1609311190
Name:BAVARO, VINCENT DOMINIC I (RN)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:DOMINIC
Last Name:BAVARO
Suffix:I
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5928 LITTLE NECK PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2532
Mailing Address - Country:US
Mailing Address - Phone:718-224-0566
Mailing Address - Fax:718-224-7544
Practice Address - Street 1:5928 LITTLE NECK PKWY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2532
Practice Address - Country:US
Practice Address - Phone:718-225-0566
Practice Address - Fax:718-224-7544
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6450831163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6450831Medicaid