Provider Demographics
NPI:1689634099
Name:VICK, STEPHEN RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RANDOLPH
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0011
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 2004
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-769-2500
Practice Address - Fax:225-769-9424
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1537772Medicaid
LAG67113Medicare UPIN
LA1537772Medicaid