Provider Demographics
NPI:1639269798
Name:VICKERS, WILLIAM ROB (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROB
Last Name:VICKERS
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 1:555 NW LAKE WHITNEY PL STE 105
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1623
Mailing Address - Country:US
Mailing Address - Phone:772-448-4865
Mailing Address - Fax:772-448-4864
Practice Address - Street 1:555 NW LAKE WHITNEY PL STE 105
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1623
Practice Address - Country:US
Practice Address - Phone:772-448-4865
Practice Address - Fax:772-448-4864
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066913207W00000X
SCLL28968208600000X
FLME111532207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006123300Medicaid
FLGF096YMedicare PIN
FL006123300Medicaid