Provider Demographics
NPI:1225288491
Name:DEBOLT, VICKI S (DO)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:S
Last Name:DEBOLT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-3745
Mailing Address - Country:US
Mailing Address - Phone:989-340-0615
Mailing Address - Fax:989-607-5154
Practice Address - Street 1:921 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-3745
Practice Address - Country:US
Practice Address - Phone:989-340-0615
Practice Address - Fax:989-607-5154
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013701208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice