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General NPI Number Information
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NPI Number | 1457474728
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Entity Type | Individual
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Provider Name | ANTONIO SISON VICENCIO III M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 21 HOSPITAL DR SUITE 230
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City | PALM COAST
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State | FL
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Zip | 32164-2452
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Country | US
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Telephone | 386-586-3466
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Fax | 386-586-3467
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Provider Business Mailing Address
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Address Line | PO BOX 354339
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City | PALM COAST
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State | FL
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Zip | 32135-4339
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Country | US
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Telephone | 386-586-3466
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Fax | 386-586-3467
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME89537
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License Number State | FL
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