Provider Demographics
NPI:1336364793
Name:VICKERY, JOHN DAVID IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:VICKERY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 DALLAS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1264
Mailing Address - Country:US
Mailing Address - Phone:770-459-0620
Mailing Address - Fax:
Practice Address - Street 1:37 CALUMET PKWY
Practice Address - Street 2:BUILDING F, SUITE 201
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-6734
Practice Address - Country:US
Practice Address - Phone:770-683-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44948207R00000X, 207K00000X
GA67624207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine