Individual
JARED MARK VINCENT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
400 E VAUGHN AVE, RUSTON, LA 71270-5951
(318) 251-0620
(318) 251-0621
Mailing address
400 E VAUGHN AVE, RUSTON, LA 71270-5951
(318) 251-0620
(318) 251-0621
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
025302
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1578967
—
LA
01
—
1619189362
GROUP NPI
LA
01
—
1639167836
PROVIDER INDIVIDUAL NPI
LA
01
—
208916544
FEDERAL TAX IDENTIFICATION NUMBER
LA
01
—
5CY25
MEDICARE GROUP
LA
Enumeration date
10/11/2005
Last updated
01/26/2012
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