Provider Demographics
NPI:1164467841
Name:VICK, DAWN R (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:R
Last Name:VICK
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 1:888 TARA BLVD
Mailing Address - Street 2:STE. E
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7818
Mailing Address - Country:US
Mailing Address - Phone:225-926-4400
Mailing Address - Fax:225-926-4409
Practice Address - Street 1:888 TARA BLVD
Practice Address - Street 2:STE. E
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7818
Practice Address - Country:US
Practice Address - Phone:225-926-4400
Practice Address - Fax:225-926-4409
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12594R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1539147Medicaid
5A426Medicare ID - Type Unspecified
LAG54582Medicare UPIN