Provider Demographics
NPI:1659596112
Name:VICK, MARY TAMARIN (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TAMARIN
Last Name:VICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:TAMARIN
Other - Last Name:RING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:208 CROSSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1468
Mailing Address - Country:US
Mailing Address - Phone:859-873-8044
Mailing Address - Fax:859-873-8045
Practice Address - Street 1:208 CROSSFIELD DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1468
Practice Address - Country:US
Practice Address - Phone:859-873-8044
Practice Address - Fax:859-873-8045
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02383208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F78724Medicare UPIN
0289402Medicare PIN