Provider Demographics
NPI:1619189362
Name:JARED VINCENT MD RUSTON EYE INSTITUTE LLC
Entity type:Organization
Organization Name:JARED VINCENT MD RUSTON EYE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-251-0620
Mailing Address - Street 1:400 E VAUGHN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5951
Mailing Address - Country:US
Mailing Address - Phone:318-251-0620
Mailing Address - Fax:
Practice Address - Street 1:400 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5951
Practice Address - Country:US
Practice Address - Phone:318-251-0620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025302207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1639167836OtherINDIVIDUAL NPI
LA1578967Medicaid
LA4K576CY25OtherMEDICARE INDIVIDUAL #
LA1639167836OtherINDIVIDUAL NPI
LA1578967Medicaid