Provider Demographics
NPI:1194771766
Name:MAGLIOCCO, VINCENT MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:MICHAEL
Last Name:MAGLIOCCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2230 TOWNE LAKE PKWY
Mailing Address - Street 2:BUILDING 700 SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5540
Mailing Address - Country:US
Mailing Address - Phone:770-591-3511
Mailing Address - Fax:770-591-3752
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BUILDING 700 SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:770-591-3511
Practice Address - Fax:770-591-3752
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA2071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1194771766OtherNPI
GA202I415396OtherPCAN
GAT77932Medicare UPIN