Provider Demographics
NPI:1265629539
Name:SKIDMORE, VICKI D (DO)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:D
Last Name:SKIDMORE
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 1:8460 COOPER CREEK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34201-2019
Mailing Address - Country:US
Mailing Address - Phone:941-360-1266
Mailing Address - Fax:941-360-1369
Practice Address - Street 1:8460 COOPER CREEK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:UNIVERSITY PARK
Practice Address - State:FL
Practice Address - Zip Code:34201-2019
Practice Address - Country:US
Practice Address - Phone:941-360-1266
Practice Address - Fax:941-360-1369
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10376208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000070500Medicaid