Provider Demographics
NPI:1336208321
Name:VICKERS, MICHAEL BRIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:VICKERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 42ND AVE SW STE 34
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4240
Mailing Address - Country:US
Mailing Address - Phone:206-937-4700
Mailing Address - Fax:206-937-4778
Practice Address - Street 1:4520 42ND AVE SW STE 34
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4240
Practice Address - Country:US
Practice Address - Phone:206-937-4700
Practice Address - Fax:206-937-4778
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000396213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1027366Medicaid
WAAB29075Medicare ID - Type Unspecified
WA1027366Medicaid