Provider Demographics
NPI:1871852426
Name:VICKERS, JOSHUA LANDON
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LANDON
Last Name:VICKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DOCTORS DR STE I
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2211
Mailing Address - Country:US
Mailing Address - Phone:912-383-6575
Mailing Address - Fax:912-383-6476
Practice Address - Street 1:100 DOCTORS DR STE I
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2211
Practice Address - Country:US
Practice Address - Phone:912-383-6575
Practice Address - Fax:912-383-6476
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN17312207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003191614AMedicaid
GA077804OtherMEDICAL LICENSE