Provider Demographics
NPI:1881621639
Name:VINCENT, THOMAS HENRY II (DPM)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HENRY
Last Name:VINCENT
Suffix:II
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W TEFFT ST
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9187
Mailing Address - Country:US
Mailing Address - Phone:805-929-8055
Mailing Address - Fax:805-929-8066
Practice Address - Street 1:620 W TEFFT ST
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9187
Practice Address - Country:US
Practice Address - Phone:805-929-8055
Practice Address - Fax:805-929-8066
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3864213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E38640Medicaid
CA480015952OtherRAILROAD MEDICARE
CARHC140373OtherRADIOGRAPHY
CARHC140373OtherRADIOGRAPHY
CA000E38640Medicaid
BV3506889OtherDEA REGISTRATION NUMBER
CAE3864Medicare PIN
5351820001Medicare NSC
CA000E38640Medicaid