Provider Demographics
NPI:1700973385
Name:VICENCIO, NORMITA DAVILA (MD)
Entity Type:Individual
Prefix:
First Name:NORMITA
Middle Name:DAVILA
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 VENOY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184
Mailing Address - Country:US
Mailing Address - Phone:734-728-2909
Mailing Address - Fax:734-728-3015
Practice Address - Street 1:4020 VENOY ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184
Practice Address - Country:US
Practice Address - Phone:734-728-2909
Practice Address - Fax:734-728-3015
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINV032288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI170375810Medicaid
1108258662OtherBCBSM
110154734OtherMEDICARE RAILROAD
0825866Medicare ID - Type Unspecified
MIE12105Medicare UPIN