Provider Demographics
NPI:1609919711
Name:VICKMAN, LAWRENCE ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ALAN
Last Name:VICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5323 BAYSHORE BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-4183
Mailing Address - Country:US
Mailing Address - Phone:813-805-0388
Mailing Address - Fax:813-805-0390
Practice Address - Street 1:5323 BAYSHORE BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-4183
Practice Address - Country:US
Practice Address - Phone:813-805-0388
Practice Address - Fax:813-805-0390
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 84580207P00000X
FLME-84580207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD93337Medicare UPIN