Provider Demographics
NPI:1043645229
Name:VINCENT, TIA BINGHAM (MD)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:BINGHAM
Last Name:VINCENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:BINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:101 SAINT JOSEPHS CANDLER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9585
Mailing Address - Country:US
Mailing Address - Phone:912-748-1999
Mailing Address - Fax:
Practice Address - Street 1:101 SAINT JOSEPHS CANDLER DR STE 200
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9585
Practice Address - Country:US
Practice Address - Phone:912-748-1999
Practice Address - Fax:912-527-1002
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330282207Q00000X
GA77781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine