Provider Demographics
NPI:1841516119
Name:TEIXEIRA, VINICIUS (MD)
Entity type:Individual
Prefix:
First Name:VINICIUS
Middle Name:
Last Name:TEIXEIRA
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 1:6435 W JEFFERSON BLVD PMB 109
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:215 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1917
Practice Address - Country:US
Practice Address - Phone:260-344-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074265B2084P0800X
IN01074265A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201258370Medicaid
IN236040160OtherMEDICARE PTAN
IN201258370Medicaid