Provider Demographics
NPI:1831121003
Name:VICENTE, GONZALO C (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:C
Last Name:VICENTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 WISCONSIN CIR STE 230
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-7005
Mailing Address - Country:US
Mailing Address - Phone:301-215-7100
Mailing Address - Fax:301-215-4144
Practice Address - Street 1:4600 N PARK AVE
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4518
Practice Address - Country:US
Practice Address - Phone:301-215-7100
Practice Address - Fax:301-215-4144
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059832207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H94881Medicare UPIN
P00139052Medicare ID - Type Unspecified