Healthcare Provider Details

I. General information

NPI: 1871660837
Provider Name (Legal Business Name): PRAKASH K VIN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W FOURTH AVE
DERRY PA
15627
US

IV. Provider business mailing address

PO BOX 215
DERRY PA
15627
US

V. Phone/Fax

Practice location:
  • Phone: 724-694-2765
  • Fax: 724-694-2870
Mailing address:
  • Phone: 724-694-2765
  • Fax: 724-694-2870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD037361L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD037361L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD037361L
License Number StatePA

VIII. Authorized Official

Name: PRAKASH K VIN
Title or Position: PRESIDENT
Credential: MD
Phone: 724-694-2765