Provider Demographics
NPI:1851331391
Name:TISA, VINCENT N (DPM)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:N
Last Name:TISA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3508
Mailing Address - Country:US
Mailing Address - Phone:215-389-7774
Mailing Address - Fax:215-389-0443
Practice Address - Street 1:2401 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3508
Practice Address - Country:US
Practice Address - Phone:215-389-7774
Practice Address - Fax:215-389-0443
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001399L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT28027Medicare UPIN