Provider Demographics
NPI:1467445171
Name:VINCIGUERRA, VAN P (OD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:P
Last Name:VINCIGUERRA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TICE BOULEVARD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677
Mailing Address - Country:US
Mailing Address - Phone:201-782-1700
Mailing Address - Fax:201-782-1749
Practice Address - Street 1:300 TICE BOULEVARD
Practice Address - Street 2:SUITE 106
Practice Address - City:WOODCLIFF LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07677
Practice Address - Country:US
Practice Address - Phone:201-782-1700
Practice Address - Fax:201-782-1749
Is Sole Proprietor?:No
Enumeration Date:2005-08-27
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4306152W00000X
NJ270A00430600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0380601Medicaid
NJ521611Medicare PIN
NJT77825Medicare UPIN
NJ0514920001Medicare NSC