Healthcare Provider Details

I. General information

NPI: 1821174772
Provider Name (Legal Business Name): ALFIN G VICENCIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE WFAN 3RD FLOOR
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD BLDG 2, STE 220
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number212630
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number212630
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number25MA12296500
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: