Provider Demographics
NPI:1861595647
Name:COLON-ALCARAZ, VICENTE M (MD)
Entity type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:M
Last Name:COLON-ALCARAZ
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 1:7210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3038
Mailing Address - Country:US
Mailing Address - Phone:618-394-0712
Mailing Address - Fax:618-394-1346
Practice Address - Street 1:7210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3038
Practice Address - Country:US
Practice Address - Phone:618-394-0712
Practice Address - Fax:618-394-1346
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084767207V00000X
MO105451207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084767Medicaid
ILB19457Medicare UPIN
IL036084767Medicaid