Provider Demographics
NPI:1861401093
Name:VINCENT, ROGER P (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:P
Last Name:VINCENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15498
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95851
Mailing Address - Country:US
Mailing Address - Phone:559-455-4000
Mailing Address - Fax:559-455-4007
Practice Address - Street 1:1121 W VINE STREET
Practice Address - Street 2:SUITE 15
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-334-4416
Practice Address - Fax:209-371-0119
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG286622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G286620Medicaid
CA00G286628Medicare PIN
CA00G286627Medicare PIN
CA00G286620Medicare PIN
CA00G286625Medicare PIN
CA00G286620Medicaid
CAA43812Medicare UPIN
CA00G286626Medicare PIN
CA00G286623Medicare PIN
CA00G286629Medicare PIN
CA300014832Medicare PIN
CA00G2866210Medicare PIN