Provider Demographics
NPI:1205930328
Name:VINCENT, ROBERT RENDELL (OD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RENDELL
Last Name:VINCENT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12406 E 86TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2500
Mailing Address - Country:US
Mailing Address - Phone:918-376-2700
Mailing Address - Fax:918-376-2722
Practice Address - Street 1:12406 E 86TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2500
Practice Address - Country:US
Practice Address - Phone:918-376-2700
Practice Address - Fax:918-376-2722
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T40697Medicare UPIN