Provider Demographics
NPI:1649236357
Name:SOLLECITO, VINCENT III (DPM)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:SOLLECITO
Suffix:III
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 1:3915 WATSON RD
Mailing Address - Street 2:200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1251
Mailing Address - Country:US
Mailing Address - Phone:314-352-2711
Mailing Address - Fax:314-644-5081
Practice Address - Street 1:3915 WATSON RD
Practice Address - Street 2:200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1251
Practice Address - Country:US
Practice Address - Phone:314-352-2711
Practice Address - Fax:314-644-5081
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00449213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302805007Medicaid
MO141657070OtherTAX ID
MOT80995Medicare UPIN
MO1251500001Medicare NSC
MO141657070OtherTAX ID