Provider Demographics
NPI:1639167836
Name:VINCENT, JARED MARK (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MARK
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 1:400 E VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5951
Mailing Address - Country:US
Mailing Address - Phone:318-251-0620
Mailing Address - Fax:318-251-0621
Practice Address - Street 1:400 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5951
Practice Address - Country:US
Practice Address - Phone:318-251-0620
Practice Address - Fax:318-251-0621
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025302207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA208916544OtherFEDERAL TAX IDENTIFICATION NUMBER
LA5CY25OtherMEDICARE GROUP
LA1619189362OtherGROUP NPI
LA1578967Medicaid
LA1639167836OtherPROVIDER INDIVIDUAL NPI
LA1619189362OtherGROUP NPI
LA4K576CY25Medicare PIN