Healthcare Provider Details

I. General information

NPI: 1467445171
Provider Name (Legal Business Name): VAN P VINCIGUERRA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2005
Last Update Date: 11/20/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TICE BOULEVARD SUITE 106
WOODCLIFF LAKE NJ
07677
US

IV. Provider business mailing address

300 TICE BOULEVARD SUITE 106
WOODCLIFF LAKE NJ
07677
US

V. Phone/Fax

Practice location:
  • Phone: 201-782-1700
  • Fax: 201-782-1749
Mailing address:
  • Phone: 201-782-1700
  • Fax: 201-782-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4306
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number270A00430600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: