Healthcare Provider Details

I. General information

NPI: 1477895712
Provider Name (Legal Business Name): AURORA GRACE VINCENT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

P.O. BOX 961205
FORT WORTH TX
76161-1205
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-7155
  • Fax:
Mailing address:
  • Phone: 817-740-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number112385
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number28108
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: