Healthcare Provider Details

I. General information

NPI: 1740228436
Provider Name (Legal Business Name): VINCENT DISILVESTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TECHNOLOGY PARK STE 109
LAKE MARY FL
32746-7107
US

IV. Provider business mailing address

121 S WILKE RD SUITE 111
ARLINGTON HEIGHTS IL
60005-1533
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-2346
  • Fax: 847-506-1917
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME138766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036087881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: