MEDICARE: DR. GORDON VINCENT M.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	2085R0202X	Diagnostic Radiology Physician	F2083	TX

General Provider Information

NPI Number	:	1538157771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON VINCENT M.D.

Provider Business Mailing Address
First Line	:	1901 SOUTH 1ST STREET
Second Line	:	IMAGING SERVICE (114T)
City	:	TEMPLE
State	:	TX
Zip	:	76504-7451
Country	:	US
Telephone Number	:	254-743-0875
Fax Number	:	254-742-4682

Provider Business Practice Location Address
First Line	:	1901 SOUTH 1ST STREET
Second Line	:	IMAGING SERVICE (114T)
City	:	TEMPLE
State	:	TX
Zip	:	76504-7451
Country	:	US
Telephone Number	:	254-743-0875
Fax Number	:	254-742-4682

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/27/2010

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