MEDICARE: VINCENT MICHAEL MAGLIOCCO O.D.

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	152W00000X	Optometrist	GA2071	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194771766	OTHER	GA	NPI
2	202I415396	OTHER	GA	PCAN

General Provider Information

NPI Number	:	1194771766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT MICHAEL MAGLIOCCO O.D.

Provider Business Mailing Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 700 SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	770-591-3511
Fax Number	:	770-591-3752

Provider Business Practice Location Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 700 SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	770-591-3511
Fax Number	:	770-591-3752

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	01/16/2013

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Directions to “ VINCENT MICHAEL MAGLIOCCO O.D.” Practice Location

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