Provider Demographics
NPI:1457354516
Name:VINCENT, CLARENCE J (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:J
Last Name:VINCENT
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:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-0808
Mailing Address - Country:US
Mailing Address - Phone:301-724-1646
Mailing Address - Fax:301-724-7429
Practice Address - Street 1:952 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1950
Practice Address - Country:US
Practice Address - Phone:301-777-3522
Practice Address - Fax:301-777-1902
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017474174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001717208OtherMT ST BLUE SHIELD
MDJ2490005OtherGHMSI
PA1012103550001Medicaid
WV0086105000Medicaid
MD411501500Medicaid
MDJ2480005OtherGHMSI
P00139754OtherRAILROAD MEDICARE
PA1012103550001Medicaid
MDJ217Medicare PIN
WV0086105000Medicaid