Provider Demographics
NPI:1386791630
Name:GORI, VINCENT D (OD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:D
Last Name:GORI
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 1:1765 GENTLE BROOK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2074
Mailing Address - Country:US
Mailing Address - Phone:702-639-1231
Mailing Address - Fax:
Practice Address - Street 1:7361 W LAKE MEAD BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1040
Practice Address - Country:US
Practice Address - Phone:702-804-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL046008712152W00000X
NV697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGF440ZMedicare PIN
ILL93911Medicare ID - Type Unspecified
ILU49813Medicare UPIN