Provider Demographics
NPI:1396876678
Name:VICARY, WILLIAM T (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:VICARY
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 1:3575 CAHUENGA BLVD W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1342
Mailing Address - Country:US
Mailing Address - Phone:323-876-9133
Mailing Address - Fax:323-876-4716
Practice Address - Street 1:3575 CAHUENGA BLVD WEST
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1342
Practice Address - Country:US
Practice Address - Phone:323-876-9133
Practice Address - Fax:323-876-4716
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30952OtherBLUE CROSS
G30952OtherAETNA
CAG30952OtherHEALTHNET
CAG30952OtherBLUE SHIELD
CAG30952Medicare PIN