Provider Demographics
NPI:1053366591
Name:FACCHIANO, VINCENT R (OD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:R
Last Name:FACCHIANO
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:E265 CHERRYVALE MALL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112
Mailing Address - Country:US
Mailing Address - Phone:815-332-2223
Mailing Address - Fax:815-332-4488
Practice Address - Street 1:E265 CHERRYVALE MALL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112
Practice Address - Country:US
Practice Address - Phone:815-332-2223
Practice Address - Fax:815-332-4488
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMF0213467OtherDEA #
ILT38697Medicare UPIN
WI000785417Medicare ID - Type Unspecified