Provider Demographics
NPI:1386073153
Name:DUBOSE, VINCENT
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SANDY TRAIL CIR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9665
Mailing Address - Country:US
Mailing Address - Phone:580-678-6934
Mailing Address - Fax:
Practice Address - Street 1:122 SANDY TRAIL CIR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9665
Practice Address - Country:US
Practice Address - Phone:580-678-6934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor