Basic Information
| Provider Information | |||||||||
| NPI: | 1003804394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINCETIC | ||||||||
| FirstName: | ANTO | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3626 E TREMONT AVE | ||||||||
| Address2: | STE 102 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184090400 | ||||||||
| FaxNumber: | 7185181281 | ||||||||
| Practice Location | |||||||||
| Address1: | 3626 E TREMONT AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104652030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184090400 | ||||||||
| FaxNumber: | 7185181281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 005796 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 02217729 | 05 | NY | MEDICAID |