Provider Demographics
NPI:1295708212
Name:VICIK, GARY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:VICIK
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 1:3608 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-6225
Mailing Address - Country:US
Mailing Address - Phone:618-397-6605
Mailing Address - Fax:618-277-1251
Practice Address - Street 1:3608 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-6225
Practice Address - Country:US
Practice Address - Phone:618-397-6605
Practice Address - Fax:618-277-1251
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-49185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0778106OtherAETNA
42561V34432OtherGROUP HEALTH PLAN
IL8215117OtherBLUE SHIELD
IL036049185Medicaid
42561V34432OtherADVANTRA
STL0307017OtherUNITED HEALTHCARE
101263OtherHEALTHLINK
202982OtherGREAT WEST
11512OtherESSENCE
IL8215117OtherBLUE SHIELD
101263OtherHEALTHLINK
STL0307017OtherUNITED HEALTHCARE