Provider Demographics
NPI:1649206392
Name:PISCIOTTA, VINCENT J (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:J
Last Name:PISCIOTTA
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:PO BOX 7237
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7237
Mailing Address - Country:US
Mailing Address - Phone:228-388-4585
Mailing Address - Fax:228-385-7610
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-388-4585
Practice Address - Fax:228-385-7610
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15334174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS040000119Medicare ID - Type Unspecified
MSE83864Medicare UPIN