Provider Demographics
NPI:1679570964
Name:HETHERINGTON, VINCENT JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JOHN
Last Name:HETHERINGTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 ROCKSIDE WOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2330
Mailing Address - Country:US
Mailing Address - Phone:216-707-8012
Mailing Address - Fax:216-643-8055
Practice Address - Street 1:6000 ROCKSIDE WOODS BLVD N
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2330
Practice Address - Country:US
Practice Address - Phone:217-707-8012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002554213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1563848Medicaid
OH0728476Medicaid
OH480031328OtherRR MEDICARE
OHCH5179OtherRR MEDICARE GROUP
OH0728476Medicaid
OHTO1121Medicare UPIN
OH1563848Medicaid
OH4310000001Medicare NSC