Provider Demographics
NPI:1306952031
Name:VINCELLI, RYAN CHRISTOPHER (OD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:CHRISTOPHER
Last Name:VINCELLI
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 1:1055 RYANS RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1721
Mailing Address - Country:US
Mailing Address - Phone:507-376-9212
Mailing Address - Fax:507-376-9235
Practice Address - Street 1:1055 RYANS RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1721
Practice Address - Country:US
Practice Address - Phone:507-376-9212
Practice Address - Fax:507-376-9235
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU91078Medicare UPIN