Provider Demographics
NPI:1003958372
Name:VICKERS, MONTGOMERY (OD)
Entity Type:Individual
Prefix:DR
First Name:MONTGOMERY
Middle Name:
Last Name:VICKERS
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 1:207 THORNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3776
Mailing Address - Country:US
Mailing Address - Phone:304-549-8841
Mailing Address - Fax:
Practice Address - Street 1:690 S WATTERS RD
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5008
Practice Address - Country:US
Practice Address - Phone:972-727-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7885152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1021398OtherWORKERS COMPENSATION
WV4321742OtherAETNA
WV0150620000Medicaid
WV410026174OtherRAILROAD MEDICARE
WA000735441OtherBCBS
WV4321742OtherAETNA
WV0482610001Medicare NSC
WV9202092Medicare PIN