Provider Demographics
NPI:1396868527
Name:BASILICE, VINCENT P (MD,PC)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:BASILICE
Suffix:
Gender:M
Credentials:MD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 NESCONSET HWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3327
Mailing Address - Country:US
Mailing Address - Phone:631-751-2020
Mailing Address - Fax:631-751-0048
Practice Address - Street 1:3400 NESCONSET HWY
Practice Address - Street 2:SUITE 107
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3327
Practice Address - Country:US
Practice Address - Phone:631-751-2020
Practice Address - Fax:631-751-0048
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127126-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00417469Medicaid
NY1679588164OtherGROUP NPI NUMBER
NY355111Medicare ID - Type Unspecified
NY00417469Medicaid