Provider Demographics
NPI:1336352012
Name:VINCENT, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-316-4979
Mailing Address - Fax:704-316-4978
Practice Address - Street 1:19485 OLD JETTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6582
Practice Address - Country:US
Practice Address - Phone:704-384-1775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39542207Q00000X
NC95-01448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985059Medicaid
NC8985059Medicaid