Provider Demographics
NPI:1952390817
Name:DEGENNARO, VINCENT A (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:A
Last Name:DEGENNARO
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 1:1201 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1624
Mailing Address - Country:US
Mailing Address - Phone:305-575-3244
Mailing Address - Fax:305-575-3255
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-3244
Practice Address - Fax:305-575-3255
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50676208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03892OtherBLUE CROSS BLUE SHIELD
FL225451OtherAVMED
FLD19041OtherVISTA
FL002517OtherNEIGHBORHOOD HEALTH
020012679OtherRAILROAD RETIREMENT
4075362OtherAETNA
FL03892OtherBLUE CROSS BLUE SHIELD
FL225451OtherAVMED
FLD19041OtherVISTA