Provider Demographics
NPI:1689626723
Name:VICENCIO, RONALD POBRE (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:POBRE
Last Name:VICENCIO
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 1:10910 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4701
Mailing Address - Country:US
Mailing Address - Phone:813-544-1465
Mailing Address - Fax:813-537-8848
Practice Address - Street 1:10910 SHELDON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4701
Practice Address - Country:US
Practice Address - Phone:813-544-1465
Practice Address - Fax:813-537-8848
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256560901Medicaid
FL080115574OtherRAILROAD MEDICARE NUMBER
FL080115574OtherRAILROAD MEDICARE NUMBER
FL28910Medicare PIN