Healthcare Provider Details

I. General information

NPI: 1184886822
Provider Name (Legal Business Name): JUSTIN MACKENZIE VINING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MAC VINING MD

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2418 E PLAZA DR
TALLAHASSEE FL
32308-5301
US

IV. Provider business mailing address

PO BOX 746645
ATLANTA GA
30374-6645
US

V. Phone/Fax

Practice location:
  • Phone: 850-629-4861
  • Fax: 850-629-4859
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number002992
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME126004
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number066664
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME126004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: