Healthcare Provider Details

I. General information

NPI: 1124064993
Provider Name (Legal Business Name): ROGER VINCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 679B
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-4751
  • Fax:
Mailing address:
  • Phone: 585-275-2475
  • Fax: 585-473-0477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number170134
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: