Provider Demographics
NPI:1790903573
Name:VICENCIO, EDUARDITA EOLANI (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDITA
Middle Name:EOLANI
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16031 TUSCOLA RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1319
Mailing Address - Country:US
Mailing Address - Phone:760-946-2020
Mailing Address - Fax:
Practice Address - Street 1:16031 TUSCOLA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1319
Practice Address - Country:US
Practice Address - Phone:760-946-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23710207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A237100Medicaid
CA00A237100Medicaid
CAA23710Medicare ID - Type Unspecified