Provider Demographics
NPI:1780790998
Name:VICENTE, VIRGILIO CORONADO (MD)
Entity type:Individual
Prefix:
First Name:VIRGILIO
Middle Name:CORONADO
Last Name:VICENTE
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 254
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-0254
Mailing Address - Country:US
Mailing Address - Phone:973-466-0300
Mailing Address - Fax:973-466-1117
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:SUITE # 3
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:973-466-0300
Practice Address - Fax:973-466-1117
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06381500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
607241OtherEMPIRE
7949804OtherUNISYS MEDICAID
8763000002OtherCIGNA
K0845OtherHORIZON BCBS
01000200803OtherAMERICHOICE
01000200800OtherAMERICHOICE
8763000OtherCIGNA
2072459000OtherAMERIHEALTH PPO HMO
2017754OtherUNITED HEALTH CARE
NJ7949804Medicaid
2327481OtherAETNA
25087OtherUNIVERSITY HEALTH PLANS
2695833OtherGHI
P3512598OtherOXFORD
607241OtherWELLCHOICE
91899OtherAMERICAID
1135312OtherHORIZON NJ HEALTH
2366072OtherAETNA
2K5847OtherACS HEALTHNET
91899OtherAMERIGROUP