Provider Demographics
NPI:1992705255
Name:PROSPERO, VINCENT (MS, PT)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:PROSPERO
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6317
Mailing Address - Country:US
Mailing Address - Phone:716-631-1212
Mailing Address - Fax:716-631-1363
Practice Address - Street 1:8705 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6317
Practice Address - Country:US
Practice Address - Phone:716-631-1212
Practice Address - Fax:716-631-1363
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010716-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY125639OtherMANAGED PHYSICAL NETWORK
NY01557042Medicaid
NY9306616OtherINDEPENDENT HEALTH
NY000623141001OtherBLUE CROSS & BLUE SHIELD
NY00025673401OtherUNIVERA
NY69932OtherGHI
NYBB6844Medicare ID - Type Unspecified