Provider Demographics
NPI:1073934352
Name:VICE, DEACON (DO)
Entity Type:Individual
Prefix:
First Name:DEACON
Middle Name:
Last Name:VICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 S. DOUGLAS
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OKLAHOMA CIRY
Mailing Address - State:OK
Mailing Address - Zip Code:73109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 S DOUGLAS AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3223
Practice Address - Country:US
Practice Address - Phone:405-636-7709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5644207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine