Provider Demographics
NPI:1114016698
Name:PHILLIPS, VICKY L (MD)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9532 MONACO DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3578
Mailing Address - Country:US
Mailing Address - Phone:714-484-8965
Mailing Address - Fax:
Practice Address - Street 1:800 S BARRANCA AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3625
Practice Address - Country:US
Practice Address - Phone:626-732-8250
Practice Address - Fax:626-858-8474
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G479050Medicaid
WG47905EMedicare ID - Type Unspecified
C36102Medicare UPIN