Provider Demographics
NPI:1982067096
Name:DEMATIO, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:DEMATIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4954 STILLWAGON RD
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 7TH AVE S
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1131
Practice Address - Country:US
Practice Address - Phone:248-860-4634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.134465207R00000X
MI4301118997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty