Provider Demographics
NPI:1801827456
Name:VICKERS, C. GREGORY (OD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:GREGORY
Last Name:VICKERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 971
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-0971
Mailing Address - Country:US
Mailing Address - Phone:715-358-3937
Mailing Address - Fax:715-358-7677
Practice Address - Street 1:9815 HWY 70 WEST
Practice Address - Street 2:SUITE 102
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-0971
Practice Address - Country:US
Practice Address - Phone:715-358-3937
Practice Address - Fax:715-358-7677
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2838-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38621700Medicaid
WI47284Medicare ID - Type Unspecified
WI38621700Medicaid