Provider Demographics
NPI:1750425419
Name:VINCENT, EDDY JACQUES (MD)
Entity type:Individual
Prefix:DR
First Name:EDDY
Middle Name:JACQUES
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 1:224 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4067
Mailing Address - Country:US
Mailing Address - Phone:718-493-6964
Mailing Address - Fax:718-493-6968
Practice Address - Street 1:224 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4067
Practice Address - Country:US
Practice Address - Phone:718-493-6964
Practice Address - Fax:718-493-6968
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133188174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112963038OtherTAX IDENTIFICATION NUMBER
NY00279869Medicaid
NYB09936Medicare UPIN
NY35F763Medicare ID - Type Unspecified