Provider Demographics
NPI:1700043197
Name:VINSON, MARY CAROLYN CLEMENTS (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY CAROLYN
Middle Name:CLEMENTS
Last Name:VINSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6550
Mailing Address - Country:US
Mailing Address - Phone:888-236-2263
Mailing Address - Fax:434-654-8961
Practice Address - Street 1:500 MARTHA JEFFERSON DR FL 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-654-5260
Practice Address - Fax:844-340-9731
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11285208600000X, 208G00000X
VA0102206935208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016155600Medicaid
FLIM203ZMedicare PIN