Provider Demographics
NPI:1134238124
Name:POLICH, VINCENT (PA)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:POLICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 LAKE LUCIEN DR STE 180
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7235
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:1410 W BROADWAY ST STE 205
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6472
Practice Address - Country:US
Practice Address - Phone:407-359-2100
Practice Address - Fax:407-359-5445
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3827WMedicare ID - Type Unspecified
FLP02176Medicare UPIN