Provider Demographics
NPI:1902835168
Name:MARIBAO, VINCENT COLINA (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:COLINA
Last Name:MARIBAO
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 1:29167 JEFFERSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1331
Mailing Address - Country:US
Mailing Address - Phone:586-498-1160
Mailing Address - Fax:586-498-1168
Practice Address - Street 1:29167 JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1331
Practice Address - Country:US
Practice Address - Phone:586-498-1160
Practice Address - Fax:586-498-1168
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063323207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4177064Medicaid
MI4177064Medicaid
MIP35550001Medicare PIN