Healthcare Provider Details

I. General information

NPI: 1881621639
Provider Name (Legal Business Name): THOMAS HENRY VINCENT II D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W TEFFT ST
NIPOMO CA
93444-9187
US

IV. Provider business mailing address

620 W TEFFT ST
NIPOMO CA
93444-9187
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-8055
  • Fax: 805-929-8066
Mailing address:
  • Phone: 805-929-8055
  • Fax: 805-929-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3864
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3864
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000E38640
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
Identifier480015952
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerRAILROAD MEDICARE
# 3
IdentifierRHC140373
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerRADIOGRAPHY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: