Provider Demographics
NPI:1669486619
Name:VICENTE, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:VICENTE
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 1:220 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-5030
Mailing Address - Country:US
Mailing Address - Phone:920-236-4700
Mailing Address - Fax:920-236-1157
Practice Address - Street 1:220 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-5030
Practice Address - Country:US
Practice Address - Phone:920-236-4700
Practice Address - Fax:920-236-1157
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI408212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000771090OtherMEDICARE PTAN
WI32562200Medicaid
WI32562200Medicaid