Provider Demographics
NPI:1841473287
Name:WILLIAM T VICARY J D M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:WILLIAM T VICARY J D M D A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:VICARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-876-9133
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:90068-1366
Mailing Address - Country:US
Mailing Address - Phone:323-876-9133
Mailing Address - Fax:323-876-4716
Practice Address - Street 1:3575 CAHUENGA BLVD W
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1366
Practice Address - Country:US
Practice Address - Phone:323-876-9133
Practice Address - Fax:323-876-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG309522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30952OtherBLUE CROSS
CAG30952OtherBLUE SHIELD
CAG30952OtherAETNA
CAG30952OtherHEALTHNET
CAG30952OtherCIGNA
CAG30952OtherUNITED HEALTHCARE
CAG30952OtherHEALTHNET