Basic Information
Provider Information
NPI: 1003802265
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VINCENT
FirstName: ALIX
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3 SEA COVE LN
Address2:  
City: NEWPORT BEACH
State: CA
PostalCode: 926606221
CountryCode: US
TelephoneNumber: 9098387864
FaxNumber:  
Practice Location
Address1: 3 SEA COVE LN
Address2:  
City: NEWPORT BEACH
State: CA
PostalCode: 926606221
CountryCode: US
TelephoneNumber: 9098387864
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/23/2005
LastUpdateDate: 07/14/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/14/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085N0700X225547MAY Allopathic & Osteopathic PhysiciansRadiologyNeuroradiology
2085R0202XME97645FLN Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

No ID Information.


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