Provider Demographics
NPI:1679699193
Name:VICENCIO, VIOLETA B (MD)
Entity Type:Individual
Prefix:DR
First Name:VIOLETA
Middle Name:B
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1075 E PACIFIC COAST HWY STE D
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-5090
Mailing Address - Country:US
Mailing Address - Phone:562-676-4596
Mailing Address - Fax:562-676-4598
Practice Address - Street 1:1075 E PACIFIC COAST HWY STE D
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5090
Practice Address - Country:US
Practice Address - Phone:562-676-4596
Practice Address - Fax:562-676-4598
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA80887Medicare UPIN