Provider Demographics
NPI:1780211821
Name:VICKERY, CELESTE MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:MICHELLE
Last Name:VICKERY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CELESTE
Other - Middle Name:
Other - Last Name:BOOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1061 MEDICAL CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8225
Mailing Address - Country:US
Mailing Address - Phone:386-917-7668
Mailing Address - Fax:386-456-1206
Practice Address - Street 1:1061 MEDICAL CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8225
Practice Address - Country:US
Practice Address - Phone:386-917-7668
Practice Address - Fax:386-456-1206
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS19786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine