Provider Demographics
NPI:1265541486
Name:VICKSTROM, CRAIG A (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:VICKSTROM
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 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2935
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:906-524-5126
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2935
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:906-524-5126
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4795539Medicaid
MI080Z710040 CV086855OtherBLUE CROSS - OFFICE
010Z760020 CV086855OtherBLUE CROSS - ER SERVICES
MI4797112Medicaid
MI4795539Medicaid
MION52150Medicare PIN
MI080Z710040 CV086855OtherBLUE CROSS - OFFICE