Provider Demographics
NPI:1184781213
Name:VICCI, VINCENT RICHARD JR (OD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:RICHARD
Last Name:VICCI
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:592 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1002
Mailing Address - Country:US
Mailing Address - Phone:908-654-7950
Mailing Address - Fax:908-654-7956
Practice Address - Street 1:592 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1002
Practice Address - Country:US
Practice Address - Phone:908-654-7950
Practice Address - Fax:908-654-7956
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00416900152WL0500X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ521477UJ2OtherMEDICARE RENDERING DOCTOR