Provider Demographics
NPI:1750383667
Name:VICKERMAN, SUSAN A (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:VICKERMAN
Suffix:
Gender:F
Credentials:DO
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 4330
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-4330
Mailing Address - Country:US
Mailing Address - Phone:970-926-6340
Mailing Address - Fax:970-926-6348
Practice Address - Street 1:50 BUCK CREEK ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-926-6340
Practice Address - Fax:970-926-6348
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01363910Medicaid
G66435Medicare UPIN
224648Medicare ID - Type Unspecified