Provider Demographics
NPI:1336145465
Name:VICK, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:VICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E REDMAN AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2316
Mailing Address - Country:US
Mailing Address - Phone:856-428-1335
Mailing Address - Fax:
Practice Address - Street 1:15 E REDMAN AVE
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2316
Practice Address - Country:US
Practice Address - Phone:856-428-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04041400207Q00000X
NJMA40414208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU53942Medicare UPIN