Provider Demographics
NPI:1033137666
Name:VICK, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:VICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-289-5443
Mailing Address - Fax:704-283-7655
Practice Address - Street 1:1106 REYNOLDS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4376
Practice Address - Country:US
Practice Address - Phone:704-289-5443
Practice Address - Fax:704-283-7655
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN21888Medicaid
NC8985081Medicaid
NC85081OtherBCBS
NC8985081Medicaid
SCN21888Medicaid
NC080176672Medicare PIN
NC202207EMedicare PIN
NCNC8590AMedicare PIN