MEDICARE: DR. RAMON OMAR VICENCIO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	MD484891	PA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1083292130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAMON OMAR VICENCIO MD

Provider Business Mailing Address
First Line	:	3509 N BROAD ST # A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19140-4105
Country	:	US
Telephone Number	:	215-707-2433
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 SHURS LN
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-2123
Country	:	US
Telephone Number	:	717-851-3038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	01/16/2026

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