Provider Demographics
NPI:1649365826
Name:VICKERS, DAVID B (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:VICKERS
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:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0843
Mailing Address - Country:US
Mailing Address - Phone:575-356-6695
Mailing Address - Fax:575-356-5948
Practice Address - Street 1:1521 W 13TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5568
Practice Address - Country:US
Practice Address - Phone:575-769-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99-321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0612426-03Medicaid
NM74435Medicaid
NM0612426-03Medicaid
348325302Medicare PIN