Healthcare Provider Details

I. General information

NPI: 1801875448
Provider Name (Legal Business Name): JOHN WADE VINCENT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 01/25/2023
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31700 TEMECULA PKWY
TEMECULA CA
92592-5896
US

IV. Provider business mailing address

41762 AVENIDA CONCHITA
MURRIETA CA
92562-8620
US

V. Phone/Fax

Practice location:
  • Phone: 951-331-2200
  • Fax:
Mailing address:
  • Phone: 951-816-5732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC180855
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11313
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5553839-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: