Provider Demographics
NPI:1831254937
Name:VICKERMAN, PETER CLIFFORD (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CLIFFORD
Last Name:VICKERMAN
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 1:15 ANCHOR DR STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-3847
Mailing Address - Country:US
Mailing Address - Phone:207-301-5600
Mailing Address - Fax:207-301-5360
Practice Address - Street 1:15 ANCHOR DR STE 103
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-3847
Practice Address - Country:US
Practice Address - Phone:207-301-5600
Practice Address - Fax:207-301-5360
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13908208000000X
MEMD18849208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN