Provider Demographics
NPI:1952307209
Name:VANN, VINCENT R JR (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:R
Last Name:VANN
Suffix:JR
Gender:
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W 76TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3004
Mailing Address - Country:US
Mailing Address - Phone:952-929-1131
Mailing Address - Fax:
Practice Address - Street 1:3601 W 76TH ST STE 300
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-3004
Practice Address - Country:US
Practice Address - Phone:952-929-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN78671207W00000X, 207WX0107X
TXK6387207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104512206Medicaid
G72640Medicare UPIN
TX8F7993Medicare PIN