Provider Demographics
NPI:1740283266
Name:VICINANZO, MATTHEW GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GERARD
Last Name:VICINANZO
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 1:1000 19TH ST S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4804
Mailing Address - Country:US
Mailing Address - Phone:205-930-0700
Mailing Address - Fax:205-930-9127
Practice Address - Street 1:1000 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-4804
Practice Address - Country:US
Practice Address - Phone:205-930-0700
Practice Address - Fax:205-930-9127
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25771207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051520716Medicaid
ALI04336Medicare UPIN
AL051520716Medicaid