Healthcare Provider Details

I. General information

NPI: 1457738676
Provider Name (Legal Business Name): EBONIE VINCENT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16405 SAND CANYON AVE STE 270
IRVINE CA
92618
US

IV. Provider business mailing address

16405 SAND CANYON AVE STE 270
IRVINE CA
92618-3792
US

V. Phone/Fax

Practice location:
  • Phone: 949-651-1202
  • Fax:
Mailing address:
  • Phone: 949-651-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5414
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number213E00000X
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: