Provider Demographics
NPI:1124181086
Name:VAN, VICKI LYNDALL (MD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNDALL
Last Name:VAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LYNDALL
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:416 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-7125
Mailing Address - Country:US
Mailing Address - Phone:770-228-5407
Mailing Address - Fax:
Practice Address - Street 1:747 S HILL ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4830
Practice Address - Country:US
Practice Address - Phone:770-228-5407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52023548OtherBLUE CROSS BLUE SHIELD
GA52023548OtherBLUE CROSS BLUE SHIELD