Provider Demographics
NPI:1023085511
Name:VICKERMAN, ROBERT PETERIS (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PETERIS
Last Name:VICKERMAN
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 1:1800 15TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4500
Mailing Address - Country:US
Mailing Address - Phone:970-352-8216
Mailing Address - Fax:970-352-5297
Practice Address - Street 1:1800 15TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4500
Practice Address - Country:US
Practice Address - Phone:970-352-8216
Practice Address - Fax:970-352-5297
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN346112086S0127X
CO47459208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3858329Medicaid
COCO306815Medicare PIN
TNH22690Medicare UPIN
TN3858329Medicare ID - Type Unspecified