Healthcare Provider Details

I. General information

NPI: 1083292130
Provider Name (Legal Business Name): RAMON OMAR VICENCIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 15198
YORK PA
17405-7198
US

IV. Provider business mailing address

PO BOX 15198
YORK PA
17405-7198
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-3038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD484891
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: