Provider Demographics
NPI:1629518014
Name:VICKERS, DAVID K
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:K
Last Name:VICKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-353-3450
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:103 JAMES ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-1504
Practice Address - Country:US
Practice Address - Phone:229-896-3424
Practice Address - Fax:229-896-3838
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily