Provider Demographics
NPI:1639165467
Name:VINCI, SAMUEL (DPM)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:VINCI
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 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:303 W OGDEN AVE FL 2
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1419
Practice Address - Country:US
Practice Address - Phone:630-510-6929
Practice Address - Fax:630-355-3273
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003414213EP1101X, 213ES0000X, 213ES0103X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003414Medicaid
IL480007268OtherRAILROAD MEDICARE
ILT37916Medicare UPIN
IL0371240002Medicare NSC
IL480007268OtherRAILROAD MEDICARE
ILK52016Medicare PIN