Provider Demographics
NPI:1902007644
Name:VICKERS, DANIEL GLEN (DO)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:GLEN
Last Name:VICKERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440-1080
Mailing Address - Country:US
Mailing Address - Phone:231-722-6005
Mailing Address - Fax:231-726-2804
Practice Address - Street 1:138 SERVICE RD STE D100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1313
Practice Address - Country:US
Practice Address - Phone:517-353-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010168562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902007644Medicaid
MI1902007644Medicaid