Provider Demographics
NPI:1194769844
Name:VINCENT, BRIAN L (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:VINCENT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1530
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-1530
Mailing Address - Country:US
Mailing Address - Phone:303-653-6255
Mailing Address - Fax:
Practice Address - Street 1:952 SWEDE GULCH RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-3713
Practice Address - Country:US
Practice Address - Phone:303-526-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2339152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU96071Medicare UPIN
CO504768Medicare ID - Type Unspecified