Provider Demographics
NPI:1669507943
Name:VANCE, LEONEL KEVIN (MD)
Entity type:Individual
Prefix:
First Name:LEONEL
Middle Name:KEVIN
Last Name:VANCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:129 FOUNTAINS BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:769-300-0730
Mailing Address - Fax:769-300-0734
Practice Address - Street 1:129 FOUNTAINS BLVD
Practice Address - Street 2:STE 201
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:769-300-0730
Practice Address - Fax:769-300-0734
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS16855208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2389791Medicaid
MS050000548Medicare ID - Type Unspecified
H27327Medicare UPIN